Provider Demographics
NPI:1477808988
Name:BATES, MATTHEW (MATTHEW BATES)
Entity type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:
Last Name:BATES
Suffix:
Gender:M
Credentials:MATTHEW BATES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4101 N POTTENGER AVE
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE
Mailing Address - State:OK
Mailing Address - Zip Code:74804-1262
Mailing Address - Country:US
Mailing Address - Phone:719-352-7058
Mailing Address - Fax:
Practice Address - Street 1:4101 N POTTENGER AVE
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:OK
Practice Address - Zip Code:74804-1262
Practice Address - Country:US
Practice Address - Phone:719-352-7058
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-20
Last Update Date:2012-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK105858163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse