MEDICARE: SHIVANA TATE PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	56539	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1487122206	OTHER	CA	NPI REGESTRY

General Provider Information

NPI Number	:	1487122206
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHIVANA TATE PA

Provider Business Mailing Address
First Line	:	136 OLD SAN ANTONIO RD STE 406
Second Line	:
City	:	BOERNE
State	:	TX
Zip	:	78006-3341
Country	:	US
Telephone Number	:	830-331-4270
Fax Number	:	830-331-4218

Provider Business Practice Location Address
First Line	:	136 OLD SAN ANTONIO RD STE 406
Second Line	:
City	:	BOERNE
State	:	TX
Zip	:	78006-3341
Country	:	US
Telephone Number	:	830-331-4270
Fax Number	:	830-331-4218

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/09/2018
Last Update Date	:	05/18/2020

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Directions to “ SHIVANA TATE PA” Practice Location

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