Healthcare Provider Details

I. General information

NPI: 1861378069
Provider Name (Legal Business Name): LUCUS TATE DNP, FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2025
Last Update Date: 10/10/2026
Certification Date: 10/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 PAINTER ST
GALAX VA
24333-3828
US

IV. Provider business mailing address

112 PAINTER ST
GALAX VA
24333-3828
US

V. Phone/Fax

Practice location:
  • Phone: 276-293-9642
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number232757
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: