Provider Demographics
NPI:1407177348
Name:TATE, BRYAN D JR (FNP-C)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:D
Last Name:TATE
Suffix:JR
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75136 N RIVER RD
Mailing Address - Street 2:
Mailing Address - City:KENTWOOD
Mailing Address - State:LA
Mailing Address - Zip Code:70444-3800
Mailing Address - Country:US
Mailing Address - Phone:985-229-0202
Mailing Address - Fax:985-229-2859
Practice Address - Street 1:919 AVENUE G
Practice Address - Street 2:
Practice Address - City:KENTWOOD
Practice Address - State:LA
Practice Address - Zip Code:70444
Practice Address - Country:US
Practice Address - Phone:985-229-0202
Practice Address - Fax:985-229-2859
Is Sole Proprietor?:No
Enumeration Date:2010-06-15
Last Update Date:2016-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN102323 AP06135363L00000X
LAAP06135363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2115014Medicaid
LA3B800Medicare PIN