Provider Demographics
NPI:1457347148
Name:GATES, BETHANY JEAN (PA C)
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:JEAN
Last Name:GATES
Suffix:
Gender:F
Credentials:PA C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 E CHESTNUT ST STE C-3
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:ME
Mailing Address - Zip Code:04330-5717
Mailing Address - Country:US
Mailing Address - Phone:804-285-4465
Mailing Address - Fax:804-285-8332
Practice Address - Street 1:6 E CHESTNUT ST STE C-3
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:ME
Practice Address - Zip Code:04330-5717
Practice Address - Country:US
Practice Address - Phone:207-626-1594
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-27
Last Update Date:2013-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110001499363A00000X
MEPA1330363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010005175Medicaid
VA010005175Medicaid
VA001004G72Medicare ID - Type Unspecified