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General NPI Number Information
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NPI Number | 1417299983
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Entity Type | Individual
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Provider Name | LATASHA N TATES PTA
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Gender | Female
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Dates
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Enumeration Date | 03/22/2013
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Last Update Date | 03/22/2013
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Provider Practice Location Address
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Address Line | 2333 MANOR DRIVE
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City | BRYAN
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State | TX
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Zip | 77802
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Country | US
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Telephone | 979-821-7327
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Fax |
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Provider Business Mailing Address
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Address Line | 117 SILKWOOD DR
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City | BRYAN
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State | TX
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Zip | 77803-3541
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Country | US
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Telephone | 832-334-1655
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number | 2054700
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License Number State | TX
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