Basic Information
Provider Information | |||||||||
NPI: | 1437484474 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | TAS | ||||||||
FirstName: | AMBER | ||||||||
MiddleName: | SHAKIRA | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | D.O. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | JOHNSON | ||||||||
OtherFirstName: | AMBER | ||||||||
OtherMiddleName: | SHAKIRA | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | D.O. | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 5398 PARK ST N | ||||||||
Address2: |   | ||||||||
City: | ST PETERSBURG | ||||||||
State: | FL | ||||||||
PostalCode: | 337091041 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7275441441 | ||||||||
FaxNumber: | 7275458263 | ||||||||
Practice Location | |||||||||
Address1: | 5398 PARK ST N | ||||||||
Address2: |   | ||||||||
City: | ST PETERSBURG | ||||||||
State: | FL | ||||||||
PostalCode: | 337091041 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7275441441 | ||||||||
FaxNumber: | 7275458263 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/08/2009 | ||||||||
LastUpdateDate: | 04/12/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | OS11158 | FL | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
ID | Type | State | Issuer | Description | 003854500 | 05 | FL |   | MEDICAID |