Provider Demographics
NPI:1942371455
Name:YAQUB, NIZAR A (MD)
Entity Type:Individual
Prefix:
First Name:NIZAR
Middle Name:A
Last Name:YAQUB
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 1:880 CASS ST
Mailing Address - Street 2:STE 108
Mailing Address - City:MONTEREY
Mailing Address - State:CA
Mailing Address - Zip Code:93940-2948
Mailing Address - Country:US
Mailing Address - Phone:831-275-4050
Mailing Address - Fax:831-275-4055
Practice Address - Street 1:880 CASS ST
Practice Address - Street 2:STE 108
Practice Address - City:MONTEREY
Practice Address - State:CA
Practice Address - Zip Code:93940-2948
Practice Address - Country:US
Practice Address - Phone:831-869-3411
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2021-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA29913174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAC41975Medicare UPIN
CA00A299130Medicare PIN