Healthcare Provider Details

I. General information

NPI: 1770562969
Provider Name (Legal Business Name): WILLIAM YATES CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/16/2006
Last Update Date: 01/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 WILLIAM CARLS DR
COMMERCE TWP MI
48382-2201
US

IV. Provider business mailing address

PO BOX 67000 DEPT 203401
DETROIT MI
48267-0002
US

V. Phone/Fax

Practice location:
  • Phone: 248-937-3307
  • Fax:
Mailing address:
  • Phone: 952-442-9770
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number4704155904
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: