Individual
EIVY TATIANA HERRERA
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA-C
Contact information
Practice address
6124 W PARKER RD STE 530, PLANO, TX 75093-8140
(469) 916-0087
Mailing address
9024 SAGEWOOD DR APT 9101, FORT WORTH, TX 76177-2285
Taxonomy
Speciality
Code
Description
License number
State
363AM0700X
Medical Physician Assistant
Primary
PA12864
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
PA12864
PA LICENSE
TX
Enumeration date
07/16/2019
Last updated
12/09/2019
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