Provider Demographics
NPI:1942375233
Name:YAMAHATA, WAYNE ICHIRO (MD)
Entity Type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:ICHIRO
Last Name:YAMAHATA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:95 SCRIPPS DR
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95825-6320
Mailing Address - Country:US
Mailing Address - Phone:916-929-1833
Mailing Address - Fax:916-929-6730
Practice Address - Street 1:95 SCRIPPS DR
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95825-6320
Practice Address - Country:US
Practice Address - Phone:916-929-1833
Practice Address - Fax:916-929-6730
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2015-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG40161208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA48116Medicare UPIN
CA00G401610Medicare ID - Type Unspecified