Provider Demographics
NPI:1275981458
Name:YOUSMAN, WINA PORIESCHA (MD)
Entity Type:Individual
Prefix:
First Name:WINA
Middle Name:PORIESCHA
Last Name:YOUSMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2610 N 3RD ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85004-1102
Mailing Address - Country:US
Mailing Address - Phone:480-610-6100
Mailing Address - Fax:
Practice Address - Street 1:617 N HUMPHREYS ST STE 102
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-3063
Practice Address - Country:US
Practice Address - Phone:480-610-6100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-29
Last Update Date:2021-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ60584207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine