Provider Demographics
NPI:1972061992
Name:GATES, RAYMOND WALTER (RPT)
Entity Type:Individual
Prefix:
First Name:RAYMOND
Middle Name:WALTER
Last Name:GATES
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2242 PATRICK LN
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-7302
Mailing Address - Country:US
Mailing Address - Phone:262-506-8083
Mailing Address - Fax:
Practice Address - Street 1:2242 PATRICK LN
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-7302
Practice Address - Country:US
Practice Address - Phone:262-506-8083
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-08
Last Update Date:2019-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI12825-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist