Provider Demographics
NPI:1508335050
Name:SHIWACH, ANITA
Entity Type:Individual
Prefix:
First Name:ANITA
Middle Name:
Last Name:SHIWACH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:941 YORK DR STE 205
Mailing Address - Street 2:
Mailing Address - City:DESOTO
Mailing Address - State:TX
Mailing Address - Zip Code:75115-2066
Mailing Address - Country:US
Mailing Address - Phone:972-283-6286
Mailing Address - Fax:
Practice Address - Street 1:941 YORK DR STE 205
Practice Address - Street 2:
Practice Address - City:DESOTO
Practice Address - State:TX
Practice Address - Zip Code:75115-2066
Practice Address - Country:US
Practice Address - Phone:972-283-6286
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-14
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA12350363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant