Provider Demographics
NPI:1245669324
Name:BATES, JEREMY CHARLES
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:CHARLES
Last Name:BATES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1847 W WHITESTONE CT
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-1308
Mailing Address - Country:US
Mailing Address - Phone:208-680-5168
Mailing Address - Fax:
Practice Address - Street 1:338 E BANNOCK ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83712-6207
Practice Address - Country:US
Practice Address - Phone:208-336-0895
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-08
Last Update Date:2020-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID41433163W00000X
IDRNA-892A367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse