1265859474 NPI number — TANESHA AUSTIN

Table of content: TANESHA AUSTIN (NPI 1265859474)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265859474 NPI number — TANESHA AUSTIN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
AUSTIN
Provider First Name:
TANESHA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1265859474
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/29/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 24648
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOUSTON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77229-4648
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
832-470-5764
Provider Business Mailing Address Fax Number:
832-404-2442

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5010 LAURA LEE LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PASADENA
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77504-2380
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
832-275-2505
Provider Business Practice Location Address Fax Number:
713-750-9187
Provider Enumeration Date:
03/25/2014

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 171M00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1265859474 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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