Basic Information
| Provider Information | |||||||||
| NPI: | 1053391037 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BATES | ||||||||
| FirstName: | ALICIA | ||||||||
| MiddleName: | KAY | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 955 HIGH ST | ||||||||
| Address2: | STE 2 | ||||||||
| City: | DECATUR | ||||||||
| State: | IN | ||||||||
| PostalCode: | 467332326 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2607248700 | ||||||||
| FaxNumber: | 2607283821 | ||||||||
| Practice Location | |||||||||
| Address1: | 1100 MERCER AVE | ||||||||
| Address2: | |||||||||
| City: | DECATUR | ||||||||
| State: | IN | ||||||||
| PostalCode: | 467332303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2607242145 | ||||||||
| FaxNumber: | 2607242145 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 71001926A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 000000373877 | 01 | IN | ANTHEM | OTHER | 200530800 | 05 | IN | MEDICAID |