Provider Demographics
NPI:1841391349
Name:YASUDA, GREGORY M (MD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:M
Last Name:YASUDA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 ONYX ST
Mailing Address - Street 2:
Mailing Address - City:KEMMERER
Mailing Address - State:WY
Mailing Address - Zip Code:83101-3214
Mailing Address - Country:US
Mailing Address - Phone:307-789-7777
Mailing Address - Fax:307-789-8888
Practice Address - Street 1:75 YELLOW CREEK RD STE 101
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:WY
Practice Address - Zip Code:82930-5205
Practice Address - Country:US
Practice Address - Phone:307-789-7777
Practice Address - Fax:307-789-8888
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2012-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY5379A208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY109094100Medicaid
WY310965OtherBLUE CROSS/BLUE SHIELD
WY020048081Medicare ID - Type UnspecifiedRAILROAD MEDICARE
WY109094100Medicaid
WYB47124Medicare UPIN