Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207R00000X | Internist | 2007016056 | MO |
N | 111NI0900X | Internist | 2007016056 | MO |
Y | 207RG0100X | Gastroenterologist | 2011014220 | MO |
NPI | 1033365358 |
---|---|
Provider Name | Dr. Yazan A Abdalla |
First Address | Saint Louis, MO 63128-2197 |
Second Address | Saint Louis, MO 63128-2197 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 18/08/2008 |
Last Update Date | 14/03/2017 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
156440048 | MEDICARE PTAN # (01) | MO |