Provider Demographics
NPI:1225516578
Name:YUSHUVAYEV, YAKOV
Entity Type:Individual
Prefix:
First Name:YAKOV
Middle Name:
Last Name:YUSHUVAYEV
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13201 N 35TH AVE STE 4B
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85029-1231
Mailing Address - Country:US
Mailing Address - Phone:602-795-0222
Mailing Address - Fax:
Practice Address - Street 1:420 E SOUTHERN AVE STE 110A
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85204-4945
Practice Address - Country:US
Practice Address - Phone:480-397-9610
Practice Address - Fax:480-397-9611
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-30
Last Update Date:2018-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ568006Medicaid