Provider Demographics
NPI:1619572948
Name:YATES, SHANE
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:
Last Name:YATES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:962 ROOSEVELT BLVD
Mailing Address - Street 2:
Mailing Address - City:ELEANOR
Mailing Address - State:WV
Mailing Address - Zip Code:25070
Mailing Address - Country:US
Mailing Address - Phone:304-533-2418
Mailing Address - Fax:
Practice Address - Street 1:962 ROOSEVELT BLVD
Practice Address - Street 2:
Practice Address - City:ELEANOR
Practice Address - State:WV
Practice Address - Zip Code:25070
Practice Address - Country:US
Practice Address - Phone:304-533-2418
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-03
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant