Healthcare Provider Details

I. General information

NPI: 1003125055
Provider Name (Legal Business Name): TATE JAMES PERQUE PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/24/2010
Last Update Date: 07/28/2020
Certification Date: 07/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1453 E BERT KOUNS INDUSTRIAL LOOP STE 318
SHREVEPORT LA
71105-6810
US

IV. Provider business mailing address

2900 SAINT MICHAEL DR STE 401
TEXARKANA TX
75503-5211
US

V. Phone/Fax

Practice location:
  • Phone: 318-681-1968
  • Fax: 318-681-1969
Mailing address:
  • Phone: 903-614-5368
  • Fax: 903-614-5343

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA.200387
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA200387
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: