Provider Demographics
NPI:1104868819
Name:YEATER, LENA MARIE
Entity type:Individual
Prefix:
First Name:LENA
Middle Name:MARIE
Last Name:YEATER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 KUYKENDALL LN
Mailing Address - Street 2:
Mailing Address - City:MOOREFIELD
Mailing Address - State:WV
Mailing Address - Zip Code:26836-1167
Mailing Address - Country:US
Mailing Address - Phone:304-530-7755
Mailing Address - Fax:304-530-7756
Practice Address - Street 1:112 KUYKENDALL LN
Practice Address - Street 2:
Practice Address - City:MOOREFIELD
Practice Address - State:WV
Practice Address - Zip Code:26836-1167
Practice Address - Country:US
Practice Address - Phone:304-530-7755
Practice Address - Fax:304-530-7756
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2010-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV01375363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVPA31761Medicare PIN