Provider Demographics
NPI:1093871923
Name:BATES, DALE EDWARD (MPAS PA-C)
Entity Type:Individual
Prefix:MR
First Name:DALE
Middle Name:EDWARD
Last Name:BATES
Suffix:
Gender:M
Credentials:MPAS PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36385 SANDY KNOLL DR
Mailing Address - Street 2:
Mailing Address - City:EASTLAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44095-5407
Mailing Address - Country:US
Mailing Address - Phone:440-479-5349
Mailing Address - Fax:440-953-0322
Practice Address - Street 1:1001 LAKESIDE AVE E
Practice Address - Street 2:SUITE 1000
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44114-1158
Practice Address - Country:US
Practice Address - Phone:440-479-5349
Practice Address - Fax:216-420-9354
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.000692363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH50.000692OtherOHIO STATE LICENSE
OH1026099OtherNATIONAL NCCPA #