Provider Demographics
NPI:1619133303
Name:GEORGE DAUGHERTY, TANISHA K (PA)
Entity Type:Individual
Prefix:
First Name:TANISHA
Middle Name:K
Last Name:GEORGE DAUGHERTY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:TANISHA
Other - Middle Name:K
Other - Last Name:GEROGE DAUGHERTY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA
Mailing Address - Street 1:2 GREENWAY PLZ
Mailing Address - Street 2:HOUSTON
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77046-0297
Mailing Address - Country:US
Mailing Address - Phone:713-798-1750
Mailing Address - Fax:713-798-1144
Practice Address - Street 1:6701 FANNIN ST
Practice Address - Street 2:HOUSTON
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-2316
Practice Address - Country:US
Practice Address - Phone:832-822-3100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-01
Last Update Date:2009-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA05666363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8L2811Medicare PIN