Provider Demographics
NPI:1578769543
Name:WESLEY TATE MD PC
Entity Type:Organization
Organization Name:WESLEY TATE MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PC
Authorized Official - Prefix:DR
Authorized Official - First Name:WESLEY
Authorized Official - Middle Name:A
Authorized Official - Last Name:TATE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:303-666-2095
Mailing Address - Street 1:1127 ORANGE PLACE
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80027
Mailing Address - Country:US
Mailing Address - Phone:303-666-2095
Mailing Address - Fax:303-666-1801
Practice Address - Street 1:2255 S 88TH ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:CO
Practice Address - Zip Code:80027-9716
Practice Address - Country:US
Practice Address - Phone:303-666-2095
Practice Address - Fax:303-666-1801
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO44990174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty