Provider Demographics
NPI:1225882178
Name:YACOB, SAMUEL RAEYU (N/A)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:RAEYU
Last Name:YACOB
Suffix:
Gender:M
Credentials:N/A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2524 W ELM ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85017-3639
Mailing Address - Country:US
Mailing Address - Phone:480-227-2603
Mailing Address - Fax:
Practice Address - Street 1:2524 W ELM ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85017-3639
Practice Address - Country:US
Practice Address - Phone:480-227-2603
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-16
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD09767801172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver