Healthcare Provider Details

I. General information

NPI: 1619133303
Provider Name (Legal Business Name): TANISHA K GEORGE DAUGHERTY PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TANISHA K GEROGE DAUGHERTY PA

II. Dates (important events)

Enumeration Date: 08/01/2008
Last Update Date: 01/12/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6701 FANNIN ST HOUSTON
HOUSTON TX
77030-2316
US

IV. Provider business mailing address

2 GREENWAY PLZ HOUSTON
HOUSTON TX
77046-0297
US

V. Phone/Fax

Practice location:
  • Phone: 832-822-3100
  • Fax:
Mailing address:
  • Phone: 713-798-1750
  • Fax: 713-798-1144

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA05666
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: