Provider Demographics
NPI:1043280704
Name:TATE, CRESTON M (DO)
Entity Type:Individual
Prefix:
First Name:CRESTON
Middle Name:M
Last Name:TATE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3421 CONCORD RD
Mailing Address - Street 2:
Mailing Address - City:YORK
Mailing Address - State:PA
Mailing Address - Zip Code:17402-9001
Mailing Address - Country:US
Mailing Address - Phone:717-356-4460
Mailing Address - Fax:717-260-3326
Practice Address - Street 1:2149 S QUEEN ST
Practice Address - Street 2:
Practice Address - City:YORK
Practice Address - State:PA
Practice Address - Zip Code:17403-4845
Practice Address - Country:US
Practice Address - Phone:717-356-4460
Practice Address - Fax:717-260-3326
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2023-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA009556L207P00000X
PAOS009556L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0016452150004Medicaid
PA0016452150010Medicaid
PA951554FLTMedicare PIN
PA0016452150004Medicaid