Provider Demographics
NPI:1174682983
Name:YASSA, EMAD (PT)
Entity Type:Individual
Prefix:
First Name:EMAD
Middle Name:
Last Name:YASSA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9865 EAGLET WAY
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80908-4798
Mailing Address - Country:US
Mailing Address - Phone:719-494-1002
Mailing Address - Fax:719-494-1824
Practice Address - Street 1:2855 INTERNATIONAL CIR
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80910-3144
Practice Address - Country:US
Practice Address - Phone:719-494-1002
Practice Address - Fax:719-494-1824
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-07
Last Update Date:2007-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO7271225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO60638320Medicaid
CO7271OtherSTATE LICENSE
COP00411530OtherRAILROAD MEDICARE
COP00411530OtherRAILROAD MEDICARE
COC807628Medicare PIN