Healthcare Provider Details

I. General information

NPI: 1528879095
Provider Name (Legal Business Name): FREDERICK JOSEPH YATES
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/15/2025
Last Update Date: 12/19/2025
Certification Date: 12/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 22ND ST
ASHLAND KY
41101-7803
US

IV. Provider business mailing address

PO BOX 790
ASHLAND KY
41105-0790
US

V. Phone/Fax

Practice location:
  • Phone: 63-241-1416
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number303527
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: