Basic Information
| Provider Information | |||||||||
| NPI: | 1881085264 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FAYETTEVILLE VA MEDICAL CENER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1111 SHELL DR | ||||||||
| Address2: | APT 60 | ||||||||
| City: | SPRING LAKE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283902050 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9104882120 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1111 SHELL DR | ||||||||
| Address2: | APT 60 | ||||||||
| City: | SPRING LAKE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283902050 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9104882120 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/06/2015 | ||||||||
| LastUpdateDate: | 02/06/2015 | ||||||||
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| AuthorizedOfficialLastName: | YAMAMOTO | ||||||||
| AuthorizedOfficialFirstName: | YOSHIKO | ||||||||
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| AuthorizedOfficialTitleorPosition: | PSYCHOLOGIST | ||||||||
| AuthorizedOfficialTelephone: | 9104882120 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | VETERAN'S ADMISTRATION | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | PHD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 283Q00000X | PS017236 | PA | Y | Hospitals | Psychiatric Hospital |
No ID Information.