INTRODUCTION: According to national data, rates of adult and congenital syphilis among American Indian/Alaska Native (AI/AN) people in 2023 are the highest of any race/ethnicity. From 2014-2023, rates of congenital syphilis among AI/AN have increased 5,250%. METHODS: An analysis of 2022-2023 national publicly available data from the Centers for Disease Control was conducted to identify the states and counties with the highest numbers of adult syphilis cases among AI/AN people. Syphilis rates were compared with Whites as a comparison group. RESULTS: Of all cases of adult syphilis among AI/AN people (n =5,152), 70% of cases (n = 3,623) occurred within five states, and 31% (n =1,606) occurred within ten counties. Within the top five states, rates of P&S syphilis among AI/AN people ranged from 2.3 to 40 times greater than Whites. Latent/unknown syphilis case rates ranged from 3.7 to 84.3 times greater among AI/AN people than Whites. Compared to 2022, the number of P&S cases decreased in four of the five states, and unknown/latent increased in all five states. Analysis by county showed high variability in year-over-year trends. DISCUSSION: Cases of syphilis among AI/AN people were highly concentrated in a subset of states and rural counties. AI/AN people had higher rates of syphilis than the comparison group of Whites, especially in unknown/latent stage of disease. Syphilis case distribution and disparities can inform how epidemic response policies and resources are allocated. Further research can identify service delivery issues that may have a greater impact on residents of tribal nations.