Healthcare Provider Details

I. General information

NPI: 1821610940
Provider Name (Legal Business Name): JAMISON FROST TATE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2020
Last Update Date: 08/14/2026
Certification Date: 08/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

SUPREME HEADQUARTERS ALLIED POWERS EUROPE (SHAPE)
APO AE
09702
US

IV. Provider business mailing address

SUPREME HEADQUARTERS ALLIED POWERS EUROPE (SHAPE)
APO AE
09702
US

V. Phone/Fax

Practice location:
  • Phone: 314-590-4664
  • Fax:
Mailing address:
  • Phone: 314-590-4664
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number89783
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: