Provider Demographics
NPI:1174893622
Name:YODER, PHILIP (ARNP)
Entity type:Individual
Prefix:
First Name:PHILIP
Middle Name:
Last Name:YODER
Suffix:
Gender:M
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4316 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:MARIANNA
Mailing Address - State:FL
Mailing Address - Zip Code:32446-2182
Mailing Address - Country:US
Mailing Address - Phone:850-526-5437
Mailing Address - Fax:
Practice Address - Street 1:4316 5TH AVE
Practice Address - Street 2:
Practice Address - City:MARIANNA
Practice Address - State:FL
Practice Address - Zip Code:32446-2182
Practice Address - Country:US
Practice Address - Phone:850-526-5437
Practice Address - Fax:850-482-6550
Is Sole Proprietor?:No
Enumeration Date:2011-12-30
Last Update Date:2012-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL3415282363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1073542825Medicaid