Healthcare Provider Details

I. General information

NPI: 1902788482
Provider Name (Legal Business Name): JEFFREY TYLER YEATER FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2025
Last Update Date: 09/11/2025
Certification Date: 09/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 WHEELING AVE
GLEN DALE WV
26038-1697
US

IV. Provider business mailing address

4501 CENTRAL AVE
SHADYSIDE OH
43947-1279
US

V. Phone/Fax

Practice location:
  • Phone: 304-845-3211
  • Fax:
Mailing address:
  • Phone: 304-551-6906
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number522089
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number106193
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: