Provider Demographics
NPI:1487886560
Name:BATES, BRANDY M (PA-C)
Entity type:Individual
Prefix:
First Name:BRANDY
Middle Name:M
Last Name:BATES
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 W 1700 S
Mailing Address - Street 2:
Mailing Address - City:CLEARFIELD
Mailing Address - State:UT
Mailing Address - Zip Code:84016-6004
Mailing Address - Country:US
Mailing Address - Phone:801-416-4474
Mailing Address - Fax:801-416-4636
Practice Address - Street 1:20 W 1700 S
Practice Address - Street 2:
Practice Address - City:CLEARFIELD
Practice Address - State:UT
Practice Address - Zip Code:84016-6004
Practice Address - Country:US
Practice Address - Phone:801-416-4474
Practice Address - Fax:801-416-4636
Is Sole Proprietor?:No
Enumeration Date:2009-08-21
Last Update Date:2020-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-808363A00000X
UT11217957-1206363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant