Provider Demographics
NPI:1437484474
Name:TAS, AMBER SHAKIRA (DO)
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:SHAKIRA
Last Name:TAS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:AMBER
Other - Middle Name:SHAKIRA
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:5398 PARK ST N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33709-1041
Mailing Address - Country:US
Mailing Address - Phone:727-544-1441
Mailing Address - Fax:727-545-8263
Practice Address - Street 1:5398 PARK ST N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33709-1041
Practice Address - Country:US
Practice Address - Phone:727-544-1441
Practice Address - Fax:727-545-8263
Is Sole Proprietor?:No
Enumeration Date:2009-10-08
Last Update Date:2017-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS11158207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003854500Medicaid
FL003854500Medicaid