Provider Demographics
NPI:1205185899
Name:SHARIATI, ROYA (PA)
Entity Type:Individual
Prefix:
First Name:ROYA
Middle Name:
Last Name:SHARIATI
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1137 ROARING SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76114-4486
Mailing Address - Country:US
Mailing Address - Phone:214-315-9604
Mailing Address - Fax:
Practice Address - Street 1:3500 GASTON AVE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75246-2017
Practice Address - Country:US
Practice Address - Phone:214-820-0111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-29
Last Update Date:2012-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA07914363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant