Provider Demographics
NPI:1710246517
Name:YAMANAKA, TETSUO (MS, ATC, PES)
Entity Type:Individual
Prefix:
First Name:TETSUO
Middle Name:
Last Name:YAMANAKA
Suffix:
Gender:M
Credentials:MS, ATC, PES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3205 QUIET MILL RD
Mailing Address - Street 2:APT. A3
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27612-4305
Mailing Address - Country:US
Mailing Address - Phone:205-239-6180
Mailing Address - Fax:
Practice Address - Street 1:4600 TRINITY RD
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607-3924
Practice Address - Country:US
Practice Address - Phone:919-513-7536
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-14
Last Update Date:2014-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC22852255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer