Provider Demographics
NPI:1194097212
Name:PATE, CLARENCE ALLAN
Entity type:Individual
Prefix:MR
First Name:CLARENCE
Middle Name:ALLAN
Last Name:PATE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5173 PALO VERDE AVE
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99709-3130
Mailing Address - Country:US
Mailing Address - Phone:907-378-8161
Mailing Address - Fax:
Practice Address - Street 1:110 2ND AVE
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-4809
Practice Address - Country:US
Practice Address - Phone:907-452-7946
Practice Address - Fax:907-452-7942
Is Sole Proprietor?:No
Enumeration Date:2012-02-06
Last Update Date:2012-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMH0157Medicaid
AKMH0157Medicaid