Provider Demographics
NPI:1538621982
Name:TATE, TABITHA MARIE
Entity type:Individual
Prefix:
First Name:TABITHA
Middle Name:MARIE
Last Name:TATE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2450 RIVERSIDE AVE # AO-401
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55454-1450
Mailing Address - Country:US
Mailing Address - Phone:608-417-0140
Mailing Address - Fax:
Practice Address - Street 1:2450 RIVERSIDE AVE # AO-401
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55454-1450
Practice Address - Country:US
Practice Address - Phone:612-626-2958
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-04
Last Update Date:2025-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125074103208000000X
MN71593208000000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics