Healthcare Provider Details

I. General information

NPI: 1154329837
Provider Name (Legal Business Name): LYLE EDGAR GATES JR. CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: LEE EDGAR GATES C.R.N.A.

II. Dates (important events)

Enumeration Date: 07/07/2005
Last Update Date: 08/24/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12606 E MISSION AVE
SPOKANE VALLEY WA
99216-3421
US

IV. Provider business mailing address

PO BOX 440
VALLEYFORD WA
99036-0440
US

V. Phone/Fax

Practice location:
  • Phone: 509-473-5723
  • Fax:
Mailing address:
  • Phone: 509-926-4329
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAP30001278
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number09907743CRNA
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRNA-488
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: