Provider Demographics
NPI:1629255302
Name:TATE, CARL FREDERICK (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:MR
First Name:CARL
Middle Name:FREDERICK
Last Name:TATE
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3549 BOULEVARD PL
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46208-4403
Mailing Address - Country:US
Mailing Address - Phone:317-920-1300
Mailing Address - Fax:
Practice Address - Street 1:3549 BOULEVARD PL
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46208-4403
Practice Address - Country:US
Practice Address - Phone:317-925-1300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-25
Last Update Date:2008-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10000107A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant