Provider Demographics
NPI:1801541578
Name:ATIATA, UBONG RAYMOND
Entity type:Individual
Prefix:MR
First Name:UBONG
Middle Name:RAYMOND
Last Name:ATIATA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17189 INTERSTATE 45 S STE 475
Mailing Address - Street 2:
Mailing Address - City:SHENANDOAH
Mailing Address - State:TX
Mailing Address - Zip Code:77385-3320
Mailing Address - Country:US
Mailing Address - Phone:936-270-3933
Mailing Address - Fax:713-791-5134
Practice Address - Street 1:17189 INTERSTATE 45 S STE 475
Practice Address - Street 2:
Practice Address - City:SHENANDOAH
Practice Address - State:TX
Practice Address - Zip Code:77385-3320
Practice Address - Country:US
Practice Address - Phone:936-270-3933
Practice Address - Fax:713-791-5134
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-21
Last Update Date:2024-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA16593363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant