Provider Demographics
NPI:1821842386
Name:BATES, KESHIA (CPT)
Entity Type:Individual
Prefix:
First Name:KESHIA
Middle Name:
Last Name:BATES
Suffix:
Gender:F
Credentials:CPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4024 ELKHART RD STE 26
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:IN
Mailing Address - Zip Code:46526-5803
Mailing Address - Country:US
Mailing Address - Phone:574-366-2023
Mailing Address - Fax:
Practice Address - Street 1:4024 ELKHART RD STE 26
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:IN
Practice Address - Zip Code:46526-5803
Practice Address - Country:US
Practice Address - Phone:574-366-2023
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-12
Last Update Date:2024-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INK4NR2N9246RP1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN9923882327Medicaid