Basic Information
| Provider Information | |||||||||
| NPI: | 1255520599 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TREECE | ||||||||
| FirstName: | YVONNE | ||||||||
| MiddleName: | PERLE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GORDON | ||||||||
| OtherFirstName: | YVONNE | ||||||||
| OtherMiddleName: | PERLE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 500 S 11TH AVE STE 400 | ||||||||
| Address2: | |||||||||
| City: | POCATELLO | ||||||||
| State: | ID | ||||||||
| PostalCode: | 832014880 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083237862 | ||||||||
| FaxNumber: | 2082327862 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 S 11TH AVE STE 204 | ||||||||
| Address2: | |||||||||
| City: | POCATELLO | ||||||||
| State: | ID | ||||||||
| PostalCode: | 832014878 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082327862 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/23/2007 | ||||||||
| LastUpdateDate: | 02/06/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 43055 | TN | N | Other Service Providers | Specialist | 207V00000X | 2008013988 | MO | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | APPLIED | 05 | TN | MEDICAID |