Basic Information
| Provider Information | |||||||||
| NPI: | 1134267677 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KHESIN | ||||||||
| FirstName: | YAKOV | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LMP-C, NCTMB | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KHESIN | ||||||||
| OtherFirstName: | JACOB | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LMP-C, NCTMB | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1530 N 115TH ST STE 207 | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981338411 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2063556781 | ||||||||
| FaxNumber: | 2065231252 | ||||||||
| Practice Location | |||||||||
| Address1: | 1530 N 115TH ST STE 207 | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981338411 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2063556781 | ||||||||
| FaxNumber: | 2065231252 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/04/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | MA00010390 | WA | Y | Other Service Providers | Specialist |
No ID Information.