Provider Demographics
NPI:1942344890
Name:TATE, WESLEY A (MD)
Entity Type:Individual
Prefix:DR
First Name:WESLEY
Middle Name:A
Last Name:TATE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4856 INNOVATION DR STE B
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-5540
Mailing Address - Country:US
Mailing Address - Phone:970-397-7815
Mailing Address - Fax:
Practice Address - Street 1:4856 INNOVATION DR STE B
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-5540
Practice Address - Country:US
Practice Address - Phone:970-397-7815
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-16
Last Update Date:2023-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO449902084P0800X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO49570871Medicaid
COCOA108477Medicare PIN