Basic Information
| Provider Information | |||||||||
| NPI: | 1497702328 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SRINIVASAN | ||||||||
| FirstName: | SHUBA | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 911230 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753911230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9729978000 | ||||||||
| FaxNumber: | 9722340813 | ||||||||
| Practice Location | |||||||||
| Address1: | 901 W 38TH ST STE 200 | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787051165 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5124214100 | ||||||||
| FaxNumber: | 5124544575 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2006 | ||||||||
| LastUpdateDate: | 04/11/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA03337 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 192819401 | 05 | TX | MEDICAID | 192819403 | 05 | TX | MEDICAID | 192819402 | 05 | TX | MEDICAID |