Provider Demographics
NPI:1376220939
Name:GATES, MADISON RAE
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:RAE
Last Name:GATES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 LIBERTY ST
Mailing Address - Street 2:
Mailing Address - City:JAMESTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:14701-3624
Mailing Address - Country:US
Mailing Address - Phone:850-619-8420
Mailing Address - Fax:
Practice Address - Street 1:505 ELLICOTT ST STE 301
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14203-1547
Practice Address - Country:US
Practice Address - Phone:716-235-3609
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-05
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY844763163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse