Basic Information
| Provider Information | |||||||||
| NPI: | 1245669324 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BATES | ||||||||
| FirstName: | JEREMY | ||||||||
| MiddleName: | CHARLES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1847 W WHITESTONE CT | ||||||||
| Address2: | |||||||||
| City: | MERIDIAN | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836461308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2086805168 | ||||||||
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| Practice Location | |||||||||
| Address1: | 338 E BANNOCK ST | ||||||||
| Address2: | |||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837126207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083360895 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2013 | ||||||||
| LastUpdateDate: | 01/17/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 41433 | ID | N | Nursing Service Providers | Registered Nurse | 367500000X | RNA-892A | ID | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.