Provider Demographics
NPI:1346086501
Name:GATEWAY HEALTH WELLNESS AND AESTHETICS
Entity type:Organization
Organization Name:GATEWAY HEALTH WELLNESS AND AESTHETICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:PANSY
Authorized Official - Middle Name:M
Authorized Official - Last Name:HARRIS-LANE
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:973-731-6253
Mailing Address - Street 1:7512 E CLINTON ST
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85260-6446
Mailing Address - Country:US
Mailing Address - Phone:973-731-6253
Mailing Address - Fax:
Practice Address - Street 1:6000 S MCCLINTOCK DR STE A&B
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85283-3266
Practice Address - Country:US
Practice Address - Phone:973-731-6253
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-06
Last Update Date:2024-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty