Healthcare Provider Details

I. General information

NPI: 1649622325
Provider Name (Legal Business Name): TREVOR YACKSYZN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2016
Last Update Date: 07/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9070 SPRING MOUNTAIN RD APT 203
LAS VEGAS NV
89117-6355
US

IV. Provider business mailing address

9070 SPRING MOUNTAIN RD APT 203
LAS VEGAS NV
89117-6355
US

V. Phone/Fax

Practice location:
  • Phone: 702-779-9176
  • Fax:
Mailing address:
  • Phone: 702-779-9176
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: