Individual
GLEN EDWARD TATE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
14558 DANVILLE PIKE, LAUREL FORK, VA 24352-3982
(276) 398-2292
(276) 398-3331
Mailing address
PO BOX 9, LAUREL FORK, VA 24352-0009
(276) 398-2292
(276) 398-3331
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
0101034417
VA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
007608942
—
VA
Enumeration date
06/09/2005
Last updated
03/05/2021
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