1598170383 NPI number — DR. TARA ETTER D.O.

Table of content: DR. TARA ETTER D.O. (NPI 1598170383)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598170383 NPI number — DR. TARA ETTER D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ETTER
Provider First Name:
TARA
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.O.
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:
1598170383
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/08/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1048 TERRACE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARION
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24354-4138
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
276-783-1827
Provider Business Mailing Address Fax Number:
276-783-2879

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1020 TERRACE DR
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
MARION
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24354-4392
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
276-783-8183
Provider Business Practice Location Address Fax Number:
276-782-9267
Provider Enumeration Date:
06/30/2014

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: 208000000X , with the licence number:  0102204770 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208000000X , with the licence number: 6907 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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