Provider Demographics
NPI:1801960679
Name:TATE, MINTA SUSAN
Entity type:Individual
Prefix:
First Name:MINTA
Middle Name:SUSAN
Last Name:TATE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MINTA
Other - Middle Name:SUSAN
Other - Last Name:IVENS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2301 S WATER
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67213
Mailing Address - Country:US
Mailing Address - Phone:316-425-7259
Mailing Address - Fax:316-263-4116
Practice Address - Street 1:2301 S WATER
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67213
Practice Address - Country:US
Practice Address - Phone:316-425-7259
Practice Address - Fax:316-263-4116
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZACVREP 2540152WL0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation