Provider Demographics
NPI:1588872824
Name:YATTAW, KEITH I (PA-C)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:I
Last Name:YATTAW
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:626 STETSON ST
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32804-5837
Mailing Address - Country:US
Mailing Address - Phone:407-648-0986
Mailing Address - Fax:
Practice Address - Street 1:1401 W SEMINOLE BLVD
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:FL
Practice Address - Zip Code:32771-6743
Practice Address - Country:US
Practice Address - Phone:407-846-2266
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-18
Last Update Date:2021-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2907333000Medicaid
FLE3986ZMedicare ID - Type Unspecified
FL2907333000Medicaid