Provider Demographics
NPI:1053320259
Name:TATE, SUSAN (PAC)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:
Last Name:TATE
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:MS
Other - First Name:SUSAN
Other - Middle Name:SHORT
Other - Last Name:TATE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:109 NATALIE LN
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72076-9378
Mailing Address - Country:US
Mailing Address - Phone:501-835-1069
Mailing Address - Fax:
Practice Address - Street 1:3401 SPRINGHILL DR
Practice Address - Street 2:SUITE 460
Practice Address - City:NORTH LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72117-2924
Practice Address - Country:US
Practice Address - Phone:501-945-1888
Practice Address - Fax:501-945-4102
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPA-168363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
S88676Medicare UPIN
5J162P050Medicare ID - Type Unspecified