Provider Demographics
NPI:1003306127
Name:GATES, ANTRIM ANSARA
Entity Type:Individual
Prefix:MR
First Name:ANTRIM
Middle Name:ANSARA
Last Name:GATES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4564 DUNDEE AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43227-2419
Mailing Address - Country:US
Mailing Address - Phone:614-515-7044
Mailing Address - Fax:
Practice Address - Street 1:4564 DUNDEE AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43227-2419
Practice Address - Country:US
Practice Address - Phone:614-515-7044
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-14
Last Update Date:2018-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH401684540814376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide