Provider Demographics
NPI:1639284938
Name:WATES, JOHN CALEB (APRN -BC, FNP)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:CALEB
Last Name:WATES
Suffix:
Gender:M
Credentials:APRN -BC, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:155 RIDGE MEDICAL PLAZA RD
Mailing Address - Street 2:
Mailing Address - City:EDGEFIELD
Mailing Address - State:SC
Mailing Address - Zip Code:29824-4531
Mailing Address - Country:US
Mailing Address - Phone:803-637-3146
Mailing Address - Fax:803-637-6597
Practice Address - Street 1:155 RIDGE MEDICAL PLAZA RD
Practice Address - Street 2:
Practice Address - City:EDGEFIELD
Practice Address - State:SC
Practice Address - Zip Code:29824-4531
Practice Address - Country:US
Practice Address - Phone:803-637-3146
Practice Address - Fax:803-637-6597
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2021-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCF3009363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP2197Medicaid
SCRHC552Medicaid
SCRHC548Medicaid