Provider Demographics
NPI:1417581265
Name:GATES, RIVER A (PA)
Entity Type:Individual
Prefix:
First Name:RIVER
Middle Name:A
Last Name:GATES
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:RIVER
Other - Middle Name:A
Other - Last Name:DAVID
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:100 MICHIGAN ST NE # MC845
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:145 MICHIGAN ST NE STE 3410
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-2563
Practice Address - Country:US
Practice Address - Phone:616-391-9945
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-02
Last Update Date:2023-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601009846363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant