Provider Demographics
NPI:1700451655
Name:YATES, GAVAN W (PA)
Entity Type:Individual
Prefix:
First Name:GAVAN
Middle Name:W
Last Name:YATES
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:GAVAN
Other - Middle Name:WILLIAM
Other - Last Name:YATES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2232 WILBORN AVE STE C
Mailing Address - Street 2:
Mailing Address - City:SOUTH BOSTON
Mailing Address - State:VA
Mailing Address - Zip Code:24592-1662
Mailing Address - Country:US
Mailing Address - Phone:434-517-3910
Mailing Address - Fax:
Practice Address - Street 1:2232 WILBORN AVE STE C
Practice Address - Street 2:
Practice Address - City:SOUTH BOSTON
Practice Address - State:VA
Practice Address - Zip Code:24592-1662
Practice Address - Country:US
Practice Address - Phone:434-517-3910
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-24
Last Update Date:2022-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110008467363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant