Healthcare Provider Details

I. General information

NPI: 1366686842
Provider Name (Legal Business Name): STEVEN BRANDON YATES IDMT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2009
Last Update Date: 04/28/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

208 W CASABLANCA AVE
CANNON AFB NM
88103-5009
US

IV. Provider business mailing address

119 E ARCADIA AVE BLDG 622 27TH SOSS/OSM
CANNON AFB NM
88103-5112
US

V. Phone/Fax

Practice location:
  • Phone: 575-784-7801
  • Fax:
Mailing address:
  • Phone: 575-784-0283
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1003X
TaxonomyIndependent Duty Medical Technicians
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: