Healthcare Provider Details

I. General information

NPI: 1578769543
Provider Name (Legal Business Name): WESLEY TATE MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/26/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2255 S 88TH ST
LOUISVILLE CO
80027-9716
US

IV. Provider business mailing address

1127 ORANGE PLACE
BOULDER CO
80027
US

V. Phone/Fax

Practice location:
  • Phone: 303-666-2095
  • Fax: 303-666-1801
Mailing address:
  • Phone: 303-666-2095
  • Fax: 303-666-1801

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number44990
License Number StateCO

VIII. Authorized Official

Name: DR. WESLEY A TATE
Title or Position: PC
Credential: MD
Phone: 303-666-2095