Provider Demographics
NPI:1124396072
Name:GATES-MANNA, SANDRA R (NP)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:R
Last Name:GATES-MANNA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1690
Mailing Address - Street 2:
Mailing Address - City:LA PORTE
Mailing Address - State:IN
Mailing Address - Zip Code:46352-1690
Mailing Address - Country:US
Mailing Address - Phone:219-326-2312
Mailing Address - Fax:219-326-2584
Practice Address - Street 1:1509 STATE ST
Practice Address - Street 2:
Practice Address - City:LA PORTE
Practice Address - State:IN
Practice Address - Zip Code:46350-3115
Practice Address - Country:US
Practice Address - Phone:219-325-5434
Practice Address - Fax:219-325-7655
Is Sole Proprietor?:No
Enumeration Date:2011-12-07
Last Update Date:2012-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28125285A363LF0000X
IN71003896A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201059520Medicaid
IN000000758275OtherANTHEM BCBS
IN151020006OtherMEDICARE PTAN