Healthcare Provider Details

I. General information

NPI: 1225380728
Provider Name (Legal Business Name): TANYA L FLYNN PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TANYA L FAVOR PA

II. Dates (important events)

Enumeration Date: 10/08/2012
Last Update Date: 11/06/2024
Certification Date: 11/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 N MAGDALEN ST
SAN ANGELO TX
76903-5400
US

IV. Provider business mailing address

PO BOX 22000
SAN ANGELO TX
76902-7200
US

V. Phone/Fax

Practice location:
  • Phone: 325-747-2344
  • Fax: 325-747-2109
Mailing address:
  • Phone: 325-747-1511
  • Fax: 325-747-2165

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA142012
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: