Provider Demographics
NPI:1023876992
Name:YAKAM, ERIC BASILE
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:BASILE
Last Name:YAKAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:ERIC
Other - Middle Name:BASILE
Other - Last Name:PETDAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2355 GALE LN
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37421-1685
Mailing Address - Country:US
Mailing Address - Phone:254-266-0801
Mailing Address - Fax:
Practice Address - Street 1:2355 GALE LN
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37421-1685
Practice Address - Country:US
Practice Address - Phone:254-266-0801
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-06
Last Update Date:2024-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN00224039376K00000X
TN142504456172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172A00000XOther Service ProvidersDriverGroup - Single Specialty
No376K00000XNursing Service Related ProvidersNurse's Aide