Healthcare Provider Details

I. General information

NPI: 1336647577
Provider Name (Legal Business Name): JASON A TATE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2018
Last Update Date: 01/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

76 FREDERICK ST
TANEYTOWN MD
21787-2135
US

IV. Provider business mailing address

PO BOX 973
WESTMINSTER MD
21158-0973
US

V. Phone/Fax

Practice location:
  • Phone: 410-756-9110
  • Fax:
Mailing address:
  • Phone: 410-848-5785
  • Fax: 410-848-5629

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DIANNE TATE
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 410-756-9110