Healthcare Provider Details

I. General information

NPI: 1689655938
Provider Name (Legal Business Name): NATACHA YAIKO YONEZUKA-GULLO PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/11/2005
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1960 NW 167TH PL, SU 205
BEAVERTON OR
97006
US

IV. Provider business mailing address

1840 NW RAMSEY DR
PORTLAND OR
97229-4241
US

V. Phone/Fax

Practice location:
  • Phone: 503-629-7500
  • Fax: 503-629-7505
Mailing address:
  • Phone: 503-223-3569
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA00953
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: