Provider Demographics
NPI:1144012188
Name:YAMEOGO, SAMUEL SIDBEWINDIN (DRIVER)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:SIDBEWINDIN
Last Name:YAMEOGO
Suffix:
Gender:M
Credentials:DRIVER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15576 SE HIGHWAY 224
Mailing Address - Street 2:
Mailing Address - City:DAMASCUS
Mailing Address - State:OR
Mailing Address - Zip Code:97089-7812
Mailing Address - Country:US
Mailing Address - Phone:415-871-5474
Mailing Address - Fax:
Practice Address - Street 1:15576 SE HIGHWAY 224
Practice Address - Street 2:
Practice Address - City:DAMASCUS
Practice Address - State:OR
Practice Address - Zip Code:97089-7812
Practice Address - Country:US
Practice Address - Phone:415-871-5474
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-17
Last Update Date:2025-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORB257000172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver