Basic Information
Provider Information | |||||||||
NPI: | 1700451655 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | YATES | ||||||||
FirstName: | GAVAN | ||||||||
MiddleName: | W | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | YATES | ||||||||
OtherFirstName: | GAVAN | ||||||||
OtherMiddleName: | WILLIAM | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 2232 WILBORN AVE STE C | ||||||||
Address2: |   | ||||||||
City: | SOUTH BOSTON | ||||||||
State: | VA | ||||||||
PostalCode: | 245921662 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4345173910 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2232 WILBORN AVE STE C | ||||||||
Address2: |   | ||||||||
City: | SOUTH BOSTON | ||||||||
State: | VA | ||||||||
PostalCode: | 245921662 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4345173910 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/24/2021 | ||||||||
LastUpdateDate: | 07/22/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/22/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 0110008467 | VA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
No ID Information.