Provider Demographics
NPI:1487122206
Name:TATE, SHIVANA (PA)
Entity type:Individual
Prefix:
First Name:SHIVANA
Middle Name:
Last Name:TATE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:136 OLD SAN ANTONIO RD STE 406
Mailing Address - Street 2:
Mailing Address - City:BOERNE
Mailing Address - State:TX
Mailing Address - Zip Code:78006-3341
Mailing Address - Country:US
Mailing Address - Phone:830-331-4270
Mailing Address - Fax:830-331-4218
Practice Address - Street 1:136 OLD SAN ANTONIO RD STE 406
Practice Address - Street 2:
Practice Address - City:BOERNE
Practice Address - State:TX
Practice Address - Zip Code:78006-3341
Practice Address - Country:US
Practice Address - Phone:830-331-4270
Practice Address - Fax:830-331-4218
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-09
Last Update Date:2020-05-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA56539363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1487122206OtherNPI REGESTRY