=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205306156
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARISA ANN YATES PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/03/2018
-----------------------------------------------------
Last Update Date | 07/21/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1575 WASHINGTON ST
-----------------------------------------------------
City | WATERTOWN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13601-9371
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-785-4155
-----------------------------------------------------
Fax | 315-779-5066
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 104 PADDOCK ST
-----------------------------------------------------
City | WATERTOWN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13601-3966
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-867-5017
-----------------------------------------------------
Fax | 315-779-5306
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 0010-08509
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 2020017114
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 026591-01
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------