Provider Demographics
NPI:1851403828
Name:SU, YAYA KISHIYAMA (MD)
Entity Type:Individual
Prefix:
First Name:YAYA
Middle Name:KISHIYAMA
Last Name:SU
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:YAYA
Other - Middle Name:KISHIYAMA
Other - Last Name:ODY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:6501 E GREENWAY PKWY
Mailing Address - Street 2:SUITE 160
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85254-2065
Mailing Address - Country:US
Mailing Address - Phone:480-948-9903
Mailing Address - Fax:480-998-5887
Practice Address - Street 1:6501 E GREENWAY PKWY
Practice Address - Street 2:SUITE 160
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85254-2065
Practice Address - Country:US
Practice Address - Phone:480-948-9903
Practice Address - Fax:480-998-5887
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ35915207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ0921700OtherBCBS PROVIDER NUMBER
AZAZ0921700OtherBCBS PROVIDER NUMBER
ASI50057Medicare UPIN