Provider Demographics
NPI:1124678859
Name:PATE, JUSTIN TIMOTHY (CRNA)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:TIMOTHY
Last Name:PATE
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1105 PLEASANT GROVE RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT EDEN
Mailing Address - State:KY
Mailing Address - Zip Code:40046-9510
Mailing Address - Country:US
Mailing Address - Phone:502-680-7048
Mailing Address - Fax:
Practice Address - Street 1:305 LANGDON ST
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:KY
Practice Address - Zip Code:42503-2750
Practice Address - Country:US
Practice Address - Phone:606-678-3288
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-15
Last Update Date:2019-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3013814367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered