Provider Demographics
NPI:1043427420
Name:RICHTER, TANA MARIE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:TANA
Middle Name:MARIE
Last Name:RICHTER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:TANA
Other - Middle Name:MARIE
Other - Last Name:RICHTER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:4705 VIA DON LUIS
Mailing Address - Street 2:
Mailing Address - City:NEWBURY PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91320-6814
Mailing Address - Country:US
Mailing Address - Phone:805-498-3047
Mailing Address - Fax:
Practice Address - Street 1:28240 AGOURA RD
Practice Address - Street 2:SUITE #102
Practice Address - City:AGOURA HILLS
Practice Address - State:CA
Practice Address - Zip Code:91301-2485
Practice Address - Country:US
Practice Address - Phone:818-706-9690
Practice Address - Fax:818-706-9692
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2012-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA14964363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant