Provider Demographics
NPI:1124411004
Name:TATE, SUNJA (NP-C)
Entity Type:Individual
Prefix:
First Name:SUNJA
Middle Name:
Last Name:TATE
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 RAWLS DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MCCOMB
Mailing Address - State:MS
Mailing Address - Zip Code:39648-2877
Mailing Address - Country:US
Mailing Address - Phone:601-684-7623
Mailing Address - Fax:
Practice Address - Street 1:300 RAWLS DRIVE
Practice Address - Street 2:SUITE 100
Practice Address - City:MCCOMB
Practice Address - State:MS
Practice Address - Zip Code:39649-2877
Practice Address - Country:US
Practice Address - Phone:601-684-7623
Practice Address - Fax:877-795-9891
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-16
Last Update Date:2015-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR878941363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily