Provider Demographics
NPI:1679828875
Name:YAZZIE, LARRY B
Entity Type:Individual
Prefix:MR
First Name:LARRY
Middle Name:B
Last Name:YAZZIE
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:PO BOX 1209
Mailing Address - Street 2:
Mailing Address - City:PINON
Mailing Address - State:AZ
Mailing Address - Zip Code:86510-1209
Mailing Address - Country:US
Mailing Address - Phone:928-675-7494
Mailing Address - Fax:
Practice Address - Street 1:9 MILES EAST OF PINON BASHAS
Practice Address - Street 2:
Practice Address - City:PINON
Practice Address - State:AZ
Practice Address - Zip Code:86510-1209
Practice Address - Country:US
Practice Address - Phone:928-675-7494
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-13
Last Update Date:2012-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
No372600000XNursing Service Related ProvidersAdult Companion