Healthcare Provider Details

I. General information

NPI: 1124072590
Provider Name (Legal Business Name): DAVID R YEAGER PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2006
Last Update Date: 03/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 E GRAY ST STE 900
LOUISVILLE KY
40202-3905
US

IV. Provider business mailing address

PO BOX 776351
CHICAGO IL
60677-6351
US

V. Phone/Fax

Practice location:
  • Phone: 502-584-7525
  • Fax: 502-584-6851
Mailing address:
  • Phone: 502-588-9490
  • Fax: 502-272-5337

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA871
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: