Provider Demographics
NPI:1669155933
Name:GATES, KOURTNEY LAUREN (PA-C)
Entity type:Individual
Prefix:MS
First Name:KOURTNEY
Middle Name:LAUREN
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 1:1531 GILLESPIE AVE
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:PA
Mailing Address - Zip Code:15946-1426
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:601 GRAY AVE
Practice Address - Street 2:
Practice Address - City:WILDWOOD
Practice Address - State:FL
Practice Address - Zip Code:34785-3520
Practice Address - Country:US
Practice Address - Phone:352-492-5611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-11
Last Update Date:2023-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9117719363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant