Provider Demographics
NPI:1386192664
Name:STOREY, TATE (CAA)
Entity Type:Individual
Prefix:
First Name:TATE
Middle Name:
Last Name:STOREY
Suffix:
Gender:M
Credentials:CAA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6159 DIMOND ST
Mailing Address - Street 2:
Mailing Address - City:JUPITER
Mailing Address - State:FL
Mailing Address - Zip Code:33458-6740
Mailing Address - Country:US
Mailing Address - Phone:561-768-1172
Mailing Address - Fax:
Practice Address - Street 1:7700 W SUNRISE BLVD
Practice Address - Street 2:
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33322-4113
Practice Address - Country:US
Practice Address - Phone:954-838-2521
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-15
Last Update Date:2016-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAA341367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant