Provider Demographics
NPI:1386887909
Name:YATES, JOSEPH RANDALL (CRNA)
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:RANDALL
Last Name:YATES
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1867
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72702-1867
Mailing Address - Country:US
Mailing Address - Phone:918-641-2551
Mailing Address - Fax:918-392-2941
Practice Address - Street 1:3215 N NORTHHILLS BLVD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703
Practice Address - Country:US
Practice Address - Phone:918-664-9892
Practice Address - Fax:918-664-2521
Is Sole Proprietor?:No
Enumeration Date:2009-04-13
Last Update Date:2018-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR50192367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR770193801OtherARKANSAS BREASTCARE
AR177926001Medicaid
OK200246350AMedicaid
AR177926001Medicaid
AR5V187Medicare PIN