Provider Demographics
NPI:1063665438
Name:YANG, MICHAEL ISHU (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:ISHU
Last Name:YANG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:392 TESCONI CT
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95401-4653
Mailing Address - Country:US
Mailing Address - Phone:707-623-9803
Mailing Address - Fax:707-843-3257
Practice Address - Street 1:392 TESCONI CT
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95401-4653
Practice Address - Country:US
Practice Address - Phone:707-623-9803
Practice Address - Fax:707-843-3257
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-29
Last Update Date:2018-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA112702207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAEV430XOtherMEDICARE PTAN
CAEV430XOtherMEDICARE PTAN