Provider Demographics
NPI:1104147958
Name:GATES, PAMELA RENEE (DPT)
Entity type:Individual
Prefix:DR
First Name:PAMELA
Middle Name:RENEE
Last Name:GATES
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:DR
Other - First Name:PAMELA
Other - Middle Name:RENEE
Other - Last Name:CALLAWAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:1001 S SHANNON AVE
Mailing Address - Street 2:
Mailing Address - City:INDIALANTIC
Mailing Address - State:FL
Mailing Address - Zip Code:32903-3334
Mailing Address - Country:US
Mailing Address - Phone:352-514-2167
Mailing Address - Fax:321-234-7910
Practice Address - Street 1:1001 S SHANNON AVE
Practice Address - Street 2:
Practice Address - City:INDIALANTIC
Practice Address - State:FL
Practice Address - Zip Code:32903-3334
Practice Address - Country:US
Practice Address - Phone:352-514-2167
Practice Address - Fax:321-234-7910
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-16
Last Update Date:2021-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT- 25556225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPT-25556OtherSTATE OF FLORIDA PT LICENSE NUMBER
FLDN699ZMedicare PIN
FLPT-25556OtherSTATE OF FLORIDA PT LICENSE NUMBER