Healthcare Provider Details

I. General information

NPI: 1205306156
Provider Name (Legal Business Name): MARISA ANN YATES PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARISA ANN BERLIN

II. Dates (important events)

Enumeration Date: 12/03/2018
Last Update Date: 07/21/2025
Certification Date: 07/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1575 WASHINGTON ST
WATERTOWN NY
13601-9371
US

IV. Provider business mailing address

104 PADDOCK ST
WATERTOWN NY
13601-3966
US

V. Phone/Fax

Practice location:
  • Phone: 315-785-4155
  • Fax: 315-779-5066
Mailing address:
  • Phone: 315-867-5017
  • Fax: 315-779-5306

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-08509
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2020017114
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number026591-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: