Provider Demographics
NPI:1609827187
Name:TATE, SHANNON NATANYA (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:NATANYA
Last Name:TATE
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18300 ROSCOE BLVD
Mailing Address - Street 2:
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91325-4105
Mailing Address - Country:US
Mailing Address - Phone:818-885-8500
Mailing Address - Fax:
Practice Address - Street 1:5601 DE SOTO AVE
Practice Address - Street 2:
Practice Address - City:WOODLAND HILLS
Practice Address - State:CA
Practice Address - Zip Code:91367-6701
Practice Address - Country:US
Practice Address - Phone:833-574-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2023-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA22283363A00000X
IL085-003472363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA2228368907Medicare NSC