Provider Demographics
NPI:1508102104
Name:GATES, CYNTHIA LEWIS
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:LEWIS
Last Name:GATES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 37365
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71133-7365
Mailing Address - Country:US
Mailing Address - Phone:318-218-9473
Mailing Address - Fax:318-631-4773
Practice Address - Street 1:5673 JEFFERSON PAIGE RD
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71119-5401
Practice Address - Country:US
Practice Address - Phone:318-218-9473
Practice Address - Fax:318-631-4773
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-31
Last Update Date:2012-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA002396694343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)