Provider Demographics
NPI:1972547800
Name:IKEN TENNISON, ANDREA K (MD)
Entity Type:Individual
Prefix:DR
First Name:ANDREA
Middle Name:K
Last Name:IKEN TENNISON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3031 IH 10 W
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78201-5159
Mailing Address - Country:US
Mailing Address - Phone:210-731-1300
Mailing Address - Fax:210-738-8025
Practice Address - Street 1:527 N LEONA ST
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78207-3110
Practice Address - Country:US
Practice Address - Phone:210-731-1300
Practice Address - Fax:210-738-8025
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2012-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK47152084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX162804201Medicaid
TX8B2197Medicare ID - Type UnspecifiedMEDICARE NO
TX162804201Medicaid