Provider Demographics
NPI:1205138591
Name:SHIVERS, EDWIN ANDREW (PA)
Entity type:Individual
Prefix:
First Name:EDWIN
Middle Name:ANDREW
Last Name:SHIVERS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3142 HORIZON RD STE 100
Mailing Address - Street 2:
Mailing Address - City:ROCKWALL
Mailing Address - State:TX
Mailing Address - Zip Code:75032-7809
Mailing Address - Country:US
Mailing Address - Phone:972-772-9600
Mailing Address - Fax:972-772-9601
Practice Address - Street 1:3142 HORIZON RD STE 100
Practice Address - Street 2:
Practice Address - City:ROCKWALL
Practice Address - State:TX
Practice Address - Zip Code:75032-7809
Practice Address - Country:US
Practice Address - Phone:972-772-9600
Practice Address - Fax:972-772-9601
Is Sole Proprietor?:No
Enumeration Date:2010-11-19
Last Update Date:2016-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA06939363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX497988ZSTUMedicare PIN
TX497988ZSTTMedicare PIN
TX497988ZSTXMedicare PIN