Provider Demographics
NPI:1669155933
Name:GATES, KOURTNEY LAUREN (PA-C)
Entity type:Individual
Prefix:MS
First Name:KOURTNEY
Middle Name:LAUREN
Last Name:GATES
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 1:1531 GILLESPIE AVE
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:PA
Mailing Address - Zip Code:15946-1426
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 SUSAN DR
Practice Address - Street 2:
Practice Address - City:JOHNSTOWN
Practice Address - State:PA
Practice Address - Zip Code:15905-2826
Practice Address - Country:US
Practice Address - Phone:814-255-1963
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-11
Last Update Date:2025-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9117719363A00000X
PAOA007470363A00000X
PAMA066595363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant