Healthcare Provider Details

I. General information

NPI: 1700206273
Provider Name (Legal Business Name): JARROD NOBUYOSHI YAMANAKA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2014
Last Update Date: 10/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10961 CLUB WEST PKWY NE STE 200
BLAINE MN
55449-5866
US

IV. Provider business mailing address

10961 CLUB WEST PKWY
BLAINE MN
55449-5866
US

V. Phone/Fax

Practice location:
  • Phone: 763-528-2922
  • Fax:
Mailing address:
  • Phone: 763-528-2992
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number60010
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: