Provider Demographics
NPI:1376742346
Name:PATES, JASON ANDREW (MD)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:ANDREW
Last Name:PATES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:JASON
Other - Middle Name:ANDREW
Other - Last Name:PATES
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:2003 KOOTENAI HEALTH WAY
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-6051
Mailing Address - Country:US
Mailing Address - Phone:208-625-4970
Mailing Address - Fax:208-625-4991
Practice Address - Street 1:980 W IRONWOOD DR STE 306
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814
Practice Address - Country:US
Practice Address - Phone:208-625-4970
Practice Address - Fax:208-625-4991
Is Sole Proprietor?:No
Enumeration Date:2007-07-11
Last Update Date:2024-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN60305207V00000X, 207VM0101X
WAMD60080627207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal Medicine
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2010237Medicaid