Provider Demographics
NPI:1871855072
Name:YARUSSO, JAMES NICHOLAS (MD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:NICHOLAS
Last Name:YARUSSO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:JAMES
Other - Middle Name:NICHOLAS
Other - Last Name:YARUSSO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:4824 E BASELINE RD
Mailing Address - Street 2:SUITE 140
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206-4678
Mailing Address - Country:US
Mailing Address - Phone:480-969-4040
Mailing Address - Fax:480-830-1042
Practice Address - Street 1:4824 E BASELINE RD
Practice Address - Street 2:SUITE 140
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-4678
Practice Address - Country:US
Practice Address - Phone:480-969-4040
Practice Address - Fax:480-830-1042
Is Sole Proprietor?:No
Enumeration Date:2012-06-13
Last Update Date:2016-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ317322083X0100X, 207RG0300X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ756430Medicaid
AZZ90122OtherPTAN
106567OtherWASHINGTON LABOR & INDUSTRY
OR01WCPBFAMedicare UPIN
AZ756430Medicaid
AZZ163087Medicare PIN
106567OtherWASHINGTON LABOR & INDUSTRY