Healthcare Provider Details

I. General information

NPI: 1487886560
Provider Name (Legal Business Name): BRANDY M BATES PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/21/2009
Last Update Date: 12/29/2025
Certification Date: 12/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2434 S FAIRWAY DR
POCATELLO ID
83201-2372
US

IV. Provider business mailing address

2434 S FAIRWAY DR
POCATELLO ID
83201-2372
US

V. Phone/Fax

Practice location:
  • Phone: 208-851-9151
  • Fax: 208-417-1822
Mailing address:
  • Phone: 208-851-9151
  • Fax: 208-417-1822

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number11217957-1206
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA-808
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: