Provider Demographics
NPI:1154329837
Name:GATES, LYLE EDGAR JR (CRNA)
Entity Type:Individual
Prefix:MR
First Name:LYLE
Middle Name:EDGAR
Last Name:GATES
Suffix:JR
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:LEE
Other - Middle Name:EDGAR
Other - Last Name:GATES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CRNA
Mailing Address - Street 1:PO BOX 440
Mailing Address - Street 2:
Mailing Address - City:VALLEYFORD
Mailing Address - State:WA
Mailing Address - Zip Code:99036-0440
Mailing Address - Country:US
Mailing Address - Phone:509-926-4329
Mailing Address - Fax:
Practice Address - Street 1:12606 E MISSION AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99216-3421
Practice Address - Country:US
Practice Address - Phone:509-473-5723
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2009-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30001278367500000X
OR09907743CRNA367500000X
IDRNA-488367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9612367Medicaid
WA9607771Medicaid
WA30129OtherL&I
WA000382017Medicare ID - Type Unspecified
WAG8876760Medicare Oscar/Certification
WA9607771Medicaid
WAG8876753Medicare PIN
WA000382017Medicare PIN
WA9612367Medicaid