Provider Demographics
NPI:1164603791
Name:YATES, JANICE (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:MRS
First Name:JANICE
Middle Name:
Last Name:YATES
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:MS
Other - First Name:JANICE
Other - Middle Name:
Other - Last Name:YATES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:CMR 402 BOX 2184
Mailing Address - Street 2:
Mailing Address - City:APO
Mailing Address - State:AE
Mailing Address - Zip Code:09180
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:CMR 402 BOX 2184
Practice Address - Street 2:
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:09180-0022
Practice Address - Country:US
Practice Address - Phone:314-486-8133
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-26
Last Update Date:2012-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA052004363AM0700X
WAPA60056456363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical