Healthcare Provider Details

I. General information

NPI: 1962640045
Provider Name (Legal Business Name): EVAN MICHAEL BATES BSW INTERN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/28/2009
Last Update Date: 01/28/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 REMSEN ST
COHOES NY
12047-2605
US

IV. Provider business mailing address

23 RICHLEE DR
CAMILLUS NY
13031-1562
US

V. Phone/Fax

Practice location:
  • Phone: 518-235-1100
  • Fax: 518-235-0079
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: