Healthcare Provider Details

I. General information

NPI: 1205138591
Provider Name (Legal Business Name): EDWIN ANDREW SHIVERS P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/19/2010
Last Update Date: 05/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3142 HORIZON RD STE 100
ROCKWALL TX
75032-7809
US

IV. Provider business mailing address

3142 HORIZON RD STE 100
ROCKWALL TX
75032-7809
US

V. Phone/Fax

Practice location:
  • Phone: 972-772-9600
  • Fax: 972-772-9601
Mailing address:
  • Phone: 972-772-9600
  • Fax: 972-772-9601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA06939
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: