Basic Information
| Provider Information | |||||||||
| NPI: | 1780167098 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PATE | ||||||||
| FirstName: | LANDON | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | BT | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2522 E 70TH ST | ||||||||
| Address2: | |||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711054002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3187953388 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2522 E 70TH ST | ||||||||
| Address2: | |||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711054002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3187953388 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2018 | ||||||||
| LastUpdateDate: | 09/12/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | RBT-18-64074 | LA | Y |
ID Information
| ID | Type | State | Issuer | Description | RBT-18-64074 | 01 | LA | BACB | OTHER |