Provider Demographics
NPI:1487155024
Name:GATES, TIMOTHY O (FNP-BC)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:O
Last Name:GATES
Suffix:
Gender:M
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16250 NORTHLAND DR STE 369
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-5208
Mailing Address - Country:US
Mailing Address - Phone:248-842-3755
Mailing Address - Fax:248-487-9410
Practice Address - Street 1:16250 NORTHLAND DR STE 369
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-1524
Practice Address - Country:US
Practice Address - Phone:248-798-8433
Practice Address - Fax:248-487-9410
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-27
Last Update Date:2020-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704297139363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily