Provider Demographics
NPI:1649714627
Name:YAMAMOTO, EUGENE ALEXANDER
Entity type:Individual
Prefix:
First Name:EUGENE
Middle Name:ALEXANDER
Last Name:YAMAMOTO
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 1:520 SUPERIOR AVE STE 270
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92663-3668
Mailing Address - Country:US
Mailing Address - Phone:800-498-3223
Mailing Address - Fax:
Practice Address - Street 1:520 SUPERIOR AVE
Practice Address - Street 2:#270
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92663-3637
Practice Address - Country:US
Practice Address - Phone:800-498-3223
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-11
Last Update Date:2023-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA54057363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant