Provider Demographics
NPI:1326211236
Name:YATES, WILDA MAY
Entity Type:Individual
Prefix:
First Name:WILDA
Middle Name:MAY
Last Name:YATES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:62 N UNION ST
Mailing Address - Street 2:
Mailing Address - City:STAR
Mailing Address - State:ID
Mailing Address - Zip Code:83669
Mailing Address - Country:US
Mailing Address - Phone:208-286-0346
Mailing Address - Fax:
Practice Address - Street 1:62 N UNION ST
Practice Address - Street 2:
Practice Address - City:STAR
Practice Address - State:ID
Practice Address - Zip Code:83669
Practice Address - Country:US
Practice Address - Phone:208-286-0346
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-11
Last Update Date:2008-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDAA134756E172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver