Provider Demographics
NPI:1437299393
Name:TATE, JOHN LEWIS (LMP)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:LEWIS
Last Name:TATE
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1125 S 3RD ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98273-4303
Mailing Address - Country:US
Mailing Address - Phone:360-336-9574
Mailing Address - Fax:360-419-7011
Practice Address - Street 1:1125 S 3RD ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98273-4303
Practice Address - Country:US
Practice Address - Phone:360-336-9574
Practice Address - Fax:360-419-7011
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA19022225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist