Provider Demographics
NPI:1154929644
Name:LITTLE, TATUM RENE (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:
First Name:TATUM
Middle Name:RENE
Last Name:LITTLE
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:200 E ANAHEIM ST
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:CA
Mailing Address - Zip Code:90744-4516
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5326 E BEVERLY BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90022-2104
Practice Address - Country:US
Practice Address - Phone:866-590-6411
Practice Address - Fax:323-476-0397
Is Sole Proprietor?:No
Enumeration Date:2020-10-15
Last Update Date:2024-10-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA58480363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant