Provider Demographics
NPI:1033185095
Name:YATES, DIANE M (PA C)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:M
Last Name:YATES
Suffix:
Gender:F
Credentials:PA C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4501 N WINCHESTER AVE
Mailing Address - Street 2:3RD FL
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640
Mailing Address - Country:US
Mailing Address - Phone:773-250-0500
Mailing Address - Fax:773-250-0497
Practice Address - Street 1:4501 N WINCHESTER AVE
Practice Address - Street 2:3RD FL
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640
Practice Address - Country:US
Practice Address - Phone:773-250-0500
Practice Address - Fax:773-250-0497
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL204330Medicare ID - Type Unspecified
P78069Medicare UPIN