Provider Demographics
NPI:1659048346
Name:KASSAYE, YONAS A
Entity Type:Individual
Prefix:
First Name:YONAS
Middle Name:A
Last Name:KASSAYE
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 1:607 WILLIAMS AVE S APT 207
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98057-2757
Mailing Address - Country:US
Mailing Address - Phone:702-415-9910
Mailing Address - Fax:
Practice Address - Street 1:8511 NE 162ND AVE
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98682-2792
Practice Address - Country:US
Practice Address - Phone:360-597-0123
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-30
Last Update Date:2021-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WIPH60864246183500000X
WAPH60864246183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAPH60864246OtherWASHINGTON STATE DEPARTMENT OF HEALTH