Provider Demographics
NPI:1396837332
Name:CALLISON, YVONNE SCOTT (PA)
Entity Type:Individual
Prefix:
First Name:YVONNE
Middle Name:SCOTT
Last Name:CALLISON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:YVONNE
Other - Middle Name:SCOTT
Other - Last Name:CALLISON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 1454
Mailing Address - Street 2:
Mailing Address - City:ROUND MOUNTAIN
Mailing Address - State:NV
Mailing Address - Zip Code:89045-1454
Mailing Address - Country:US
Mailing Address - Phone:775-379-0785
Mailing Address - Fax:
Practice Address - Street 1:1742 OREGON ST
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96001-1717
Practice Address - Country:US
Practice Address - Phone:530-251-6523
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2023-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV570363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002416101Medicaid
S40203Medicare UPIN