Basic Information
| Provider Information | |||||||||
| NPI: | 1780796359 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | YARRIS-EWERT | ||||||||
| FirstName: | LINDA | ||||||||
| MiddleName: | MARIAN | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PH.D, M.D., P.A. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 12545 NEW BRITTANY BLVD | ||||||||
| Address2: | SUITE 26 | ||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339073625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2392742071 | ||||||||
| FaxNumber: | 2392742075 | ||||||||
| Practice Location | |||||||||
| Address1: | 12545 NEW BRITTANY BLVD | ||||||||
| Address2: | SUITE 26 | ||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339073625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2392742071 | ||||||||
| FaxNumber: | 2392742075 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 12/12/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | ME0064852 | FL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | AS19990440001 | 01 | FL | CIGNA INSURANCE | OTHER | 194736 | 01 | FL | STAYWELL HEALTHY KIDS | OTHER | 23801 | 01 | FL | BLUE CROSS BLUE SHIELD | OTHER | 2666792 | 01 | FL | AETNA HEALTHCARE | OTHER | 374409400 | 05 | FL | MEDICAID |