Provider Demographics
NPI:1962571331
Name:BATES, MELISSA D (PA)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:D
Last Name:BATES
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:D
Other - Last Name:CUSHMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3450 POTOMAC WAY
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-4970
Mailing Address - Country:US
Mailing Address - Phone:208-557-2900
Mailing Address - Fax:208-557-2910
Practice Address - Street 1:808 PANCHERI DR
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:93402-3344
Practice Address - Country:US
Practice Address - Phone:208-552-6900
Practice Address - Fax:208-552-4973
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2018-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA513363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807116800Medicaid
1666894Medicare PIN
Q40324Medicare UPIN