Provider Demographics
NPI:1558442400
Name:SHREVE, TANYA (PA)
Entity Type:Individual
Prefix:
First Name:TANYA
Middle Name:
Last Name:SHREVE
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 1:6911 PISTOL RANGE RD STE 102
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33635-6335
Mailing Address - Country:US
Mailing Address - Phone:813-888-9924
Mailing Address - Fax:
Practice Address - Street 1:6911 PISTOL RANGE RD STE 102
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33635-6335
Practice Address - Country:US
Practice Address - Phone:813-888-9924
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9100202363A00000X
NMPA2005-0021363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLQ03564Medicare UPIN