Provider Demographics
NPI:1003125055
Name:PERQUE, TATE JAMES (PA-C)
Entity Type:Individual
Prefix:
First Name:TATE
Middle Name:JAMES
Last Name:PERQUE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2900 SAINT MICHAEL DR STE 401
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75503-5211
Mailing Address - Country:US
Mailing Address - Phone:903-614-5368
Mailing Address - Fax:903-614-5343
Practice Address - Street 1:1453 E BERT KOUNS INDUSTRIAL LOOP STE 318
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-6810
Practice Address - Country:US
Practice Address - Phone:318-681-1968
Practice Address - Fax:318-681-1969
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-24
Last Update Date:2020-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPA.200387363AS0400X
LAPA200387363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2125362Medicaid