Basic Information
| Provider Information | |||||||||
| NPI: | 1932418589 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | YATES | ||||||||
| FirstName: | EVAN | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1735 27TH ST STE B06 | ||||||||
| Address2: | |||||||||
| City: | PORTSMOUTH | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456622681 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403568681 | ||||||||
| FaxNumber: | 7403537900 | ||||||||
| Practice Location | |||||||||
| Address1: | 1711 27TH ST STE 102 | ||||||||
| Address2: | |||||||||
| City: | PORTSMOUTH | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456622657 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403561709 | ||||||||
| FaxNumber: | 7403533027 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/30/2010 | ||||||||
| LastUpdateDate: | 12/16/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | 50.003136 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 0087133 | 05 | OH | MEDICAID |