Provider Demographics
NPI:1629586573
Name:AYERS, RAVEN SHELBY (PA-C)
Entity Type:Individual
Prefix:
First Name:RAVEN
Middle Name:SHELBY
Last Name:AYERS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:RAVEN
Other - Middle Name:SHELBY
Other - Last Name:FALLS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:3515 RICHMOND RD
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75503-0711
Mailing Address - Country:US
Mailing Address - Phone:903-791-9355
Mailing Address - Fax:903-793-0496
Practice Address - Street 1:125 ARKANSAS BLVD
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:AR
Practice Address - Zip Code:71854-1963
Practice Address - Country:US
Practice Address - Phone:870-772-9355
Practice Address - Fax:870-772-9360
Is Sole Proprietor?:No
Enumeration Date:2018-01-12
Last Update Date:2023-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPA-759363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant