Provider Demographics
NPI:1699013607
Name:BATES, ALICIA AUGUSTINE (NP-C)
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:AUGUSTINE
Last Name:BATES
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:MS
Other - First Name:ALICIA
Other - Middle Name:TERRI
Other - Last Name:AUGUSTINE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP-C
Mailing Address - Street 1:2500 N STATE ST
Mailing Address - Street 2:DIVISION OF CARDIOLOGY
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4500
Mailing Address - Country:US
Mailing Address - Phone:601-984-5678
Mailing Address - Fax:
Practice Address - Street 1:9001 SUMMA AVE
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70809-3726
Practice Address - Country:US
Practice Address - Phone:225-761-5586
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-25
Last Update Date:2016-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR885839363LF0000X
LAAP08060363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2379585Medicaid
MS01727036Medicaid
MS293250YR8UMedicare PIN
LA2379585Medicaid