Provider Demographics
NPI:1205306156
Name:YATES, MARISA ANN (PA-C)
Entity type:Individual
Prefix:
First Name:MARISA
Middle Name:ANN
Last Name:YATES
Suffix:
Gender:F
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 1:10020 EUPHRATES RIVER VALLEY ROAD
Mailing Address - Street 2:
Mailing Address - City:FORT DRUM
Mailing Address - State:NY
Mailing Address - Zip Code:13602-6519
Mailing Address - Country:US
Mailing Address - Phone:315-772-5516
Mailing Address - Fax:
Practice Address - Street 1:11050 MOUNT BELVEDERE BLVD
Practice Address - Street 2:
Practice Address - City:FORT DRUM
Practice Address - State:NY
Practice Address - Zip Code:13602-5438
Practice Address - Country:US
Practice Address - Phone:153-772-5717
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-03
Last Update Date:2021-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-08509363A00000X
MO2020017114363A00000X
NY026591-01363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant