Basic Information
| Provider Information | |||||||||
| NPI: | 1528154325 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | YEASAYER | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | EGAR | ||||||||
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| Credential: | P.A.-C. | ||||||||
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| OtherLastName: | GIBSON | ||||||||
| OtherFirstName: | MICHELLE | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 936 | ||||||||
| Address2: | |||||||||
| City: | LONDON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 407430936 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6063307835 | ||||||||
| FaxNumber: | 6063307825 | ||||||||
| Practice Location | |||||||||
| Address1: | 227 FALCON DR STE 104 | ||||||||
| Address2: | |||||||||
| City: | MT STERLING | ||||||||
| State: | KY | ||||||||
| PostalCode: | 403539792 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8594975459 | ||||||||
| FaxNumber: | 8594975470 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2006 | ||||||||
| LastUpdateDate: | 07/03/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA055 | KY | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AS0400X | PA055 | KY | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363A00000X | PA055 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 4000501 | 01 | KY | MEDICARE LAB GROUP | OTHER | 95005138 | 05 | KY | MEDICAID | CB5773 | 01 | KY | RR MEDICARE GROUP | OTHER | P00245022 | 01 | KY | RR MEDICARE PIN | OTHER | 37903705 | 01 | KY | MEDICAID GROUP LAB | OTHER |