Provider Demographics
NPI:1265561021
Name:TATE, LISA MARIE (APN)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:MARIE
Last Name:TATE
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:780 KUENZLI ST
Mailing Address - Street 2:STE 202
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89502-0845
Mailing Address - Country:US
Mailing Address - Phone:775-982-5068
Mailing Address - Fax:775-982-5496
Practice Address - Street 1:975 RYLAND ST
Practice Address - Street 2:STE 100
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89502-1667
Practice Address - Country:US
Practice Address - Phone:775-982-5000
Practice Address - Fax:775-982-5225
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2014-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVAPRN000913363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
12188992OtherCAQH
NV1265561021Medicaid