Provider Demographics
NPI:1205306156
Name:YATES, MARISA ANN (PA-C)
Entity type:Individual
Prefix:
First Name:MARISA
Middle Name:ANN
Last Name:YATES
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MARISA
Other - Middle Name:ANN
Other - Last Name:BERLIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:104 PADDOCK ST
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-3966
Mailing Address - Country:US
Mailing Address - Phone:315-867-5017
Mailing Address - Fax:315-779-5306
Practice Address - Street 1:1575 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-9371
Practice Address - Country:US
Practice Address - Phone:315-785-4155
Practice Address - Fax:315-779-5066
Is Sole Proprietor?:No
Enumeration Date:2018-12-03
Last Update Date:2025-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-08509363A00000X
MO2020017114363A00000X
NY026591-01363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant