Provider Demographics
NPI:1649412560
Name:TATE, LARA MITCHELL (PA-C)
Entity type:Individual
Prefix:MRS
First Name:LARA
Middle Name:MITCHELL
Last Name:TATE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8402 HARCOURT RD STE 120
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46260-2006
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8402 HARCOURT RD STE 120
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260-2006
Practice Address - Country:US
Practice Address - Phone:317-338-4303
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-25
Last Update Date:2023-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10001051363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
INM400023951Medicare PIN
INP01141662Medicare PIN