Provider Demographics
NPI:1497839724
Name:YEATES, LESLIE D (PA-C)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:D
Last Name:YEATES
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 SOUTH KENNEDY DR
Mailing Address - Street 2:
Mailing Address - City:BRADLEY
Mailing Address - State:IL
Mailing Address - Zip Code:60915
Mailing Address - Country:US
Mailing Address - Phone:815-928-8050
Mailing Address - Fax:815-928-9858
Practice Address - Street 1:400 SOUTH KENNEDY DR
Practice Address - Street 2:
Practice Address - City:BRADLEY
Practice Address - State:IL
Practice Address - Zip Code:60915
Practice Address - Country:US
Practice Address - Phone:815-928-8050
Practice Address - Fax:815-928-9858
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085-001038363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical