Healthcare Provider Details

I. General information

NPI: 1720405830
Provider Name (Legal Business Name): JACK M YANG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2014
Last Update Date: 08/23/2022
Certification Date: 08/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3129 N RAINBOW BLVD
LAS VEGAS NV
89108-4578
US

IV. Provider business mailing address

3129 N RAINBOW BLVD
LAS VEGAS NV
89108-4578
US

V. Phone/Fax

Practice location:
  • Phone: 725-220-8457
  • Fax: 833-749-0355
Mailing address:
  • Phone: 725-220-8457
  • Fax: 833-749-0355

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number17243
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: