Provider Demographics
NPI:1770290579
Name:BOQUIREN, TIARA ROTER (PA-C)
Entity type:Individual
Prefix:
First Name:TIARA
Middle Name:ROTER
Last Name:BOQUIREN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6115 SULFUR SPRING DR
Mailing Address - Street 2:
Mailing Address - City:KILLEEN
Mailing Address - State:TX
Mailing Address - Zip Code:76542-5283
Mailing Address - Country:US
Mailing Address - Phone:808-222-0870
Mailing Address - Fax:
Practice Address - Street 1:3801 N LAMAR BLVD STE 300
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78756-4080
Practice Address - Country:US
Practice Address - Phone:512-206-3600
Practice Address - Fax:512-407-1874
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-01
Last Update Date:2024-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X, 390200000X
TXPA18123363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program