Provider Demographics
NPI:1063835460
Name:ELACKATT, TINA T (PA-C)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:T
Last Name:ELACKATT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:TINA
Other - Middle Name:T
Other - Last Name:THANKACHAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:6818 SPANISH BAY CT
Mailing Address - Street 2:
Mailing Address - City:MISSOURI CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77459-5071
Mailing Address - Country:US
Mailing Address - Phone:832-216-9991
Mailing Address - Fax:
Practice Address - Street 1:4690 SWEETWATER BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:SUGAR LAND
Practice Address - State:TX
Practice Address - Zip Code:77479-3467
Practice Address - Country:US
Practice Address - Phone:281-565-0033
Practice Address - Fax:281-565-0568
Is Sole Proprietor?:No
Enumeration Date:2014-01-22
Last Update Date:2015-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA05158363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant