Provider Demographics
NPI:1891373544
Name:GOATES, JEREMY A (ATC)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:A
Last Name:GOATES
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4910 CORPORATE CENTRE DR STE 150
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:KS
Mailing Address - Zip Code:66047-1002
Mailing Address - Country:US
Mailing Address - Phone:857-312-9127
Mailing Address - Fax:
Practice Address - Street 1:4910 CORPORATE CENTRE DR STE 150
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:KS
Practice Address - Zip Code:66047-1002
Practice Address - Country:US
Practice Address - Phone:785-312-9127
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-01
Last Update Date:2021-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS24004982255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer