Provider Demographics
NPI:1710001466
Name:YARAMATA, DOMINIQUE (PHN MEDICAL CLERK)
Entity Type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:
Last Name:YARAMATA
Suffix:
Gender:F
Credentials:PHN MEDICAL CLERK
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 LIMESTONE COURT
Mailing Address - Street 2:
Mailing Address - City:PEACH SPRINGS
Mailing Address - State:AZ
Mailing Address - Zip Code:86434
Mailing Address - Country:US
Mailing Address - Phone:928-769-1562
Mailing Address - Fax:
Practice Address - Street 1:943 HUALAPAI WAY
Practice Address - Street 2:
Practice Address - City:PEACH SPRINGS
Practice Address - State:AZ
Practice Address - Zip Code:86434
Practice Address - Country:US
Practice Address - Phone:928-769-2900
Practice Address - Fax:928-769-2971
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374700000XNursing Service Related ProvidersTechnician
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1598795825Medicare ID - Type UnspecifiedPEACH SPRINGS CLINIC