Provider Demographics
NPI:1194772384
Name:BATES, MANDY JO (PA-C)
Entity type:Individual
Prefix:MS
First Name:MANDY
Middle Name:JO
Last Name:BATES
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MANDY
Other - Middle Name:JO
Other - Last Name:LENTZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:1535 GULL RD
Mailing Address - Street 2:SUITE 020
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49048
Mailing Address - Country:US
Mailing Address - Phone:269-381-4577
Mailing Address - Fax:269-381-6409
Practice Address - Street 1:1535 GULL RD
Practice Address - Street 2:SUITE 020
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49048-1650
Practice Address - Country:US
Practice Address - Phone:269-381-4577
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2008-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601004616363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical