Provider Demographics
NPI:1275582538
Name:YEARTY, CHARLES D (CRNA)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:D
Last Name:YEARTY
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:POST OFFICE BOX 235019
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36177-8045
Mailing Address - Country:US
Mailing Address - Phone:770-812-5730
Mailing Address - Fax:770-838-8563
Practice Address - Street 1:705 DIXIE ST
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117-3818
Practice Address - Country:US
Practice Address - Phone:770-836-9666
Practice Address - Fax:770-836-9212
Is Sole Proprietor?:No
Enumeration Date:2006-05-06
Last Update Date:2010-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-037195367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51526410OtherBLUE SHIELD
ALP00197496OtherPALMETTO GBA
AL051526410Medicaid
AL051526410Medicare ID - Type Unspecified
ALP00197496OtherPALMETTO GBA