Provider Demographics
NPI:1477156859
Name:GATES, MARY ANN (LAC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ANN
Last Name:GATES
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2800 N LOMBARD ST # 115
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97217-6234
Mailing Address - Country:US
Mailing Address - Phone:971-235-0680
Mailing Address - Fax:
Practice Address - Street 1:6913 SE FOSTER RD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97206-4547
Practice Address - Country:US
Practice Address - Phone:503-235-7653
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-18
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC202061171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist