Provider Demographics
NPI:1497702328
Name:SRINIVASAN, SHUBA (PA)
Entity Type:Individual
Prefix:
First Name:SHUBA
Middle Name:
Last Name:SRINIVASAN
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:PO BOX 911230
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75391-1230
Mailing Address - Country:US
Mailing Address - Phone:972-997-8000
Mailing Address - Fax:972-234-0813
Practice Address - Street 1:901 W 38TH ST STE 200
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78705-1165
Practice Address - Country:US
Practice Address - Phone:512-421-4100
Practice Address - Fax:512-454-4575
Is Sole Proprietor?:No
Enumeration Date:2006-05-27
Last Update Date:2017-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA03337363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX192819401Medicaid
TX192819403Medicaid
TX192819402Medicaid
TXTXB156580Medicare PIN
TX84P423Medicare PIN
TXP00364792Medicare PIN
TX192819403Medicaid
TX551903YK4EMedicare PIN