Healthcare Provider Details

I. General information

NPI: 1902883564
Provider Name (Legal Business Name): JEANNE YEAGLE P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/27/2005
Last Update Date: 12/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11050 MOUNT BELVEDERE BLVD
FORT DRUM NY
13602-5438
US

IV. Provider business mailing address

261 TENEYCK ST APT 5
WATERTOWN NY
13601-3902
US

V. Phone/Fax

Practice location:
  • Phone: 315-772-0859
  • Fax:
Mailing address:
  • Phone: 315-782-0491
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number085-002033
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: