Provider Demographics
NPI:1255705166
Name:YEZHEVSKY, YAKOV
Entity type:Individual
Prefix:
First Name:YAKOV
Middle Name:
Last Name:YEZHEVSKY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9505 NE 180TH ST
Mailing Address - Street 2:APT 201
Mailing Address - City:BOTHELL
Mailing Address - State:WA
Mailing Address - Zip Code:98011-3367
Mailing Address - Country:US
Mailing Address - Phone:206-227-7546
Mailing Address - Fax:
Practice Address - Street 1:9505 NE 180TH ST
Practice Address - Street 2:APT 201
Practice Address - City:BOTHELL
Practice Address - State:WA
Practice Address - Zip Code:98011-3367
Practice Address - Country:US
Practice Address - Phone:206-227-7546
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-17
Last Update Date:2015-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60079835174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA646584OtherEVERGREEN CARE NETWORK