Healthcare Provider Details

I. General information

NPI: 1386192664
Provider Name (Legal Business Name): TATE STOREY CAA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/15/2016
Last Update Date: 09/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7700 W SUNRISE BLVD
PLANTATION FL
33322-4113
US

IV. Provider business mailing address

6159 DIMOND ST
JUPITER FL
33458-6740
US

V. Phone/Fax

Practice location:
  • Phone: 954-838-2521
  • Fax:
Mailing address:
  • Phone: 561-768-1172
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License NumberAA341
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: