Provider Demographics
NPI:1669996385
Name:YASSA, SHADY KHAIRY ISKANDER
Entity type:Individual
Prefix:
First Name:SHADY
Middle Name:KHAIRY ISKANDER
Last Name:YASSA
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 1:224 BEACH 20TH ST LOWR LEVEL
Mailing Address - Street 2:
Mailing Address - City:FAR ROCKAWAY
Mailing Address - State:NY
Mailing Address - Zip Code:11691-3618
Mailing Address - Country:US
Mailing Address - Phone:718-337-1100
Mailing Address - Fax:718-337-1101
Practice Address - Street 1:1829 PUTNAM AVE
Practice Address - Street 2:
Practice Address - City:RIDGEWOOD
Practice Address - State:NY
Practice Address - Zip Code:11385-4247
Practice Address - Country:US
Practice Address - Phone:718-337-1100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-03
Last Update Date:2017-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist