Provider Demographics
NPI:1124086103
Name:FUKUDA, YASUO (ATC)
Entity type:Individual
Prefix:MR
First Name:YASUO
Middle Name:
Last Name:FUKUDA
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4201 S DECATUR BLVD
Mailing Address - Street 2:APT 2142
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89103-5875
Mailing Address - Country:US
Mailing Address - Phone:702-735-9425
Mailing Address - Fax:
Practice Address - Street 1:4201 S DECATUR BLVD
Practice Address - Street 2:APT 2142
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89103-5875
Practice Address - Country:US
Practice Address - Phone:702-735-9425
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV05060242255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer