=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093727828
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SANDRA YASSKIN L.O.T.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/12/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 302 E 24TH ST
-----------------------------------------------------
City | BRYAN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77803-5303
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 979-821-9474
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2901 JENNIFER DR
-----------------------------------------------------
City | COLLEGE STATION
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77845-5755
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 979-696-6661
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 100920
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------