Provider Demographics
NPI:1679529200
Name:YAZVAC, SUSAN MARIE (DC, DACBR)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:MARIE
Last Name:YAZVAC
Suffix:
Gender:F
Credentials:DC, DACBR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4010 SE 42ND AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97206-3211
Mailing Address - Country:US
Mailing Address - Phone:503-771-8105
Mailing Address - Fax:503-777-5683
Practice Address - Street 1:4010 SE 42ND AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97206-3211
Practice Address - Country:US
Practice Address - Phone:503-771-8105
Practice Address - Fax:503-777-5683
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-25
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2014111NR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NR0200XChiropractic ProvidersChiropractorRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORU30867Medicare UPIN