MEDICARE: SHANNON NATANYA TATE PHYSICIAN ASSISTANT

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	22283	CA

General Provider Information

NPI Number	:	1609827187
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANNON NATANYA TATE PHYSICIAN ASSISTANT

Provider Business Mailing Address
First Line	:	18300 ROSCOE BLVD
Second Line	:
City	:	NORTHRIDGE
State	:	CA
Zip	:	91325-4105
Country	:	US
Telephone Number	:	818-885-8500
Fax Number	:

Provider Business Practice Location Address
First Line	:	5601 DE SOTO AVE
Second Line	:
City	:	WOODLAND HILLS
State	:	CA
Zip	:	91367-6701
Country	:	US
Telephone Number	:	833-574-2273
Fax Number	:

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

Provider Enumeration Date	:	05/12/2006
Last Update Date	:	02/21/2023

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