Provider Demographics
NPI:1154167195
Name:YATES, GRAYSON EDWARD (STUDENT)
Entity type:Individual
Prefix:
First Name:GRAYSON
Middle Name:EDWARD
Last Name:YATES
Suffix:
Gender:M
Credentials:STUDENT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1818 PAT DR
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MO
Mailing Address - Zip Code:64506-3213
Mailing Address - Country:US
Mailing Address - Phone:615-743-5850
Mailing Address - Fax:
Practice Address - Street 1:1818 PAT DR
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MO
Practice Address - Zip Code:64506-3213
Practice Address - Country:US
Practice Address - Phone:615-743-5850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-08
Last Update Date:2024-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program