Provider Demographics
NPI:1992497242
Name:TATE, BRENT TYLER (DO)
Entity type:Individual
Prefix:
First Name:BRENT
Middle Name:TYLER
Last Name:TATE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2501 CAPEHART RD
Mailing Address - Street 2:
Mailing Address - City:OFFUTT AFB
Mailing Address - State:NE
Mailing Address - Zip Code:68113-1043
Mailing Address - Country:US
Mailing Address - Phone:402-294-2056
Mailing Address - Fax:
Practice Address - Street 1:2501 CAPEHART RD
Practice Address - Street 2:
Practice Address - City:OFFUTT AFB
Practice Address - State:NE
Practice Address - Zip Code:68113-1043
Practice Address - Country:US
Practice Address - Phone:402-294-2056
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-24
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE9586207Q00000X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine