Provider Demographics
NPI:1306557913
Name:TATE, KYLEE ROSE (PA-C)
Entity type:Individual
Prefix:
First Name:KYLEE
Middle Name:ROSE
Last Name:TATE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KYLEE
Other - Middle Name:ROSE
Other - Last Name:HUMPHREYS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:16635 N 43RD AVE # 100
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85053-2707
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:16635 N 43RD AVE # 100
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85053-2707
Practice Address - Country:US
Practice Address - Phone:480-553-6168
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-06
Last Update Date:2024-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant