Basic Information
| Provider Information | |||||||||
| NPI: | 1497249718 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BATES | ||||||||
| FirstName: | MYRANDA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10175 FORTUNE PKWY UNIT 903 | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322566755 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9045380713 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 334 GREENE ST UNIT 10 | ||||||||
| Address2: | |||||||||
| City: | AUGUSTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 309011619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8082821402 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2018 | ||||||||
| LastUpdateDate: | 01/31/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/31/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | RBT-1858589 | Y |
No ID Information.