Basic Information
Provider Information | |||||||||
NPI: | 1588800981 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | NASR | ||||||||
FirstName: | JOHN | ||||||||
MiddleName: | YACOUB | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 9156 | ||||||||
Address2: |   | ||||||||
City: | MORGANTOWN | ||||||||
State: | WV | ||||||||
PostalCode: | 265069156 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3042934123 | ||||||||
FaxNumber: | 3042857126 | ||||||||
Practice Location | |||||||||
Address1: | 1 MEDICAL CENTER DRIVE | ||||||||
Address2: |   | ||||||||
City: | MORGANTOWN | ||||||||
State: | WV | ||||||||
PostalCode: | 26506 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3042934123 | ||||||||
FaxNumber: | 3042857126 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/06/2009 | ||||||||
LastUpdateDate: | 11/17/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MD444706 | PA | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207RG0100X | MD444706 | PA | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | 207RG0100X | 26159 | WV | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
ID | Type | State | Issuer | Description | 3810028541 | 05 | WV |   | MEDICAID | 1027538460001 | 05 | PA |   | MEDICAID |