Provider Demographics
NPI:1306356118
Name:PARKER, TATSIANA (PA-C)
Entity Type:Individual
Prefix:
First Name:TATSIANA
Middle Name:
Last Name:PARKER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:558 SAINT CHARLES DR STE 110
Mailing Address - Street 2:
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91360-3967
Mailing Address - Country:US
Mailing Address - Phone:805-449-8781
Mailing Address - Fax:805-449-4224
Practice Address - Street 1:558 SAINT CHARLES DR STE 110
Practice Address - Street 2:
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91360-3967
Practice Address - Country:US
Practice Address - Phone:805-449-8781
Practice Address - Fax:805-449-4224
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-06
Last Update Date:2020-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA55026363A00000X
CA363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant