Provider Demographics
NPI:1689656647
Name:YASSA, NADINE H (MD)
Entity Type:Individual
Prefix:
First Name:NADINE
Middle Name:H
Last Name:YASSA
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 1:991 RESERVE DRIVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95678-1340
Mailing Address - Country:US
Mailing Address - Phone:916-789-8811
Mailing Address - Fax:916-789-8809
Practice Address - Street 1:991 RESERVE DRIVE
Practice Address - Street 2:SUITE A
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95678-1340
Practice Address - Country:US
Practice Address - Phone:916-789-8811
Practice Address - Fax:916-789-8809
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-16
Last Update Date:2013-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA487202084N0402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child Neurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00190174OtherRAILROAD MEDICARE
CA00A487201Medicaid
CACGP159990OtherMEDICAID CCS PROVIDER NUMBER
CA00A487202OtherMEDICARE PTAN - INDIVIDUAL
P00190174OtherRAILROAD MEDICARE
CA00A487200Medicare ID - Type UnspecifiedINDIVIDUAL
CA00A487202OtherMEDICARE PTAN - INDIVIDUAL