Healthcare Provider Details

I. General information

NPI: 1184611519
Provider Name (Legal Business Name): SUSAN J TATE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2005
Last Update Date: 05/28/2025
Certification Date: 05/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4076 NEELY ROAD
FORT WAINWRIGHT AK
99703
US

IV. Provider business mailing address

4076 NEELY ROAD
FT WAINWRIGHT AK
99703
US

V. Phone/Fax

Practice location:
  • Phone: 907-361-5479
  • Fax:
Mailing address:
  • Phone: 907-361-5689
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number4295
License Number StateAK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierMD0991
Identifier TypeMEDICAID
Identifier StateAK
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: