Provider Demographics
NPI:1114093614
Name:GATES, ROGER DEAN (CRNA)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:DEAN
Last Name:GATES
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3018 W PELICAN DR
Mailing Address - Street 2:
Mailing Address - City:OAK ISLAND
Mailing Address - State:NC
Mailing Address - Zip Code:28465-7743
Mailing Address - Country:US
Mailing Address - Phone:910-278-9365
Mailing Address - Fax:910-278-1288
Practice Address - Street 1:3018 W PELICAN DR
Practice Address - Street 2:
Practice Address - City:OAK ISLAND
Practice Address - State:NC
Practice Address - Zip Code:28465-7743
Practice Address - Country:US
Practice Address - Phone:910-278-9365
Practice Address - Fax:910-278-1288
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC055985367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered