Healthcare Provider Details

I. General information

NPI: 1568123610
Provider Name (Legal Business Name): AMY ALLISON YEATES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/30/2021
Last Update Date: 08/06/2025
Certification Date: 08/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2428 N STOKESBERRY PL
MERIDIAN ID
83646-5035
US

IV. Provider business mailing address

2428 N STOKESBERRY PL
MERIDIAN ID
83646-5035
US

V. Phone/Fax

Practice location:
  • Phone: 208-895-0050
  • Fax: 855-543-3086
Mailing address:
  • Phone: 208-895-0050
  • Fax: 855-543-3086

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2471259
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: