Provider Demographics
NPI:1043239593
Name:GATES, BRIAN LEE (DPM)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:LEE
Last Name:GATES
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:521 LOGAN BOULEVARD LAKEMONT
Mailing Address - Street 2:
Mailing Address - City:ALTOONA
Mailing Address - State:PA
Mailing Address - Zip Code:16602-5619
Mailing Address - Country:US
Mailing Address - Phone:814-943-9885
Mailing Address - Fax:814-943-5492
Practice Address - Street 1:521 LOGAN BOULEVARD LAKEMONT
Practice Address - Street 2:
Practice Address - City:ALTOONA
Practice Address - State:PA
Practice Address - Zip Code:16602-5619
Practice Address - Country:US
Practice Address - Phone:814-943-9885
Practice Address - Fax:814-943-5492
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2007-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC002225L213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0343300001Medicare NSC
PAT29798Medicare UPIN
PA084466Medicare ID - Type UnspecifiedPODIATRST