Provider Demographics
NPI:1164929543
Name:TATE, TERRELL SEAN (BOCP, CO)
Entity Type:Individual
Prefix:
First Name:TERRELL
Middle Name:SEAN
Last Name:TATE
Suffix:
Gender:M
Credentials:BOCP, CO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1661 INTERNATIONAL PLACE DR STE 400
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-1431
Mailing Address - Country:US
Mailing Address - Phone:901-818-3175
Mailing Address - Fax:
Practice Address - Street 1:1661 INTERNATIONAL DRIVE
Practice Address - Street 2:SUITE 400
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38120-1431
Practice Address - Country:US
Practice Address - Phone:901-340-2008
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-11
Last Update Date:2021-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPRO1301744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNPRO130OtherTN DEPT OF HEALTH DIVISION OF RELATED BOARDS