Provider Demographics
NPI:1396406146
Name:YATES, ALICIA MARIE
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:MARIE
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 1:6350 CENTER DR STE 200
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23502-4107
Mailing Address - Country:US
Mailing Address - Phone:757-213-5700
Mailing Address - Fax:
Practice Address - Street 1:1051 LOFTIS BLVD STE 100
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23606-3069
Practice Address - Country:US
Practice Address - Phone:757-873-9400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-04
Last Update Date:2022-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110008738363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant