Healthcare Provider Details

I. General information

NPI: 1558638700
Provider Name (Legal Business Name): RENE YATES PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/16/2011
Last Update Date: 11/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8390 CHAMPIONS GATE BLVD SUITE 306
CHAMPIONS GATE FL
33896-8310
US

IV. Provider business mailing address

8390 CHAMPIONS GATE BLVD SUITE 306
CHAMPIONS GATE FL
33896-8310
US

V. Phone/Fax

Practice location:
  • Phone: 407-390-1677
  • Fax: 407-390-1765
Mailing address:
  • Phone: 407-390-1677
  • Fax: 407-390-1765

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9106224
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: