Provider Demographics
NPI:1790027381
Name:PATE, IVAN (PTA)
Entity Type:Individual
Prefix:MR
First Name:IVAN
Middle Name:
Last Name:PATE
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:156 WINDING WAY APT C
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:GA
Mailing Address - Zip Code:31763-5055
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2405 OSLER CT
Practice Address - Street 2:SUITE 200
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31707-0214
Practice Address - Country:US
Practice Address - Phone:229-883-4009
Practice Address - Fax:229-883-4320
Is Sole Proprietor?:No
Enumeration Date:2013-03-21
Last Update Date:2013-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPTA002360225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant