1023178035 NPI number — MRS. TARA RENE ROBERTS MS, CCC-A

Table of content: MRS. TARA RENE ROBERTS MS, CCC-A (NPI 1023178035)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023178035 NPI number — MRS. TARA RENE ROBERTS MS, CCC-A

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROBERTS
Provider First Name:
TARA
Provider Middle Name:
RENE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MS, CCC-A
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:
1023178035
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/27/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2025 MORSE AVE
Provider Second Line Business Mailing Address:
HEAD AND NECK SURGERY DEPARTMENT - 3E
Provider Business Mailing Address City Name:
SACRAMENTO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95825-2115
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
916-973-7913
Provider Business Mailing Address Fax Number:
916-973-7971

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2025 MORSE AVE
Provider Second Line Business Practice Location Address:
HEAD AND NECK SURGERY DEPARTMENT - 3E
Provider Business Practice Location Address City Name:
SACRAMENTO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95825-2115
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
916-973-7913
Provider Business Practice Location Address Fax Number:
916-973-7971
Provider Enumeration Date:
12/11/2006

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: 231H00000X , with the licence number:  AU1936 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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