1609321074 NPI number — MRS. TARA L BOYLE PA-C

Table of content: MRS. TARA L BOYLE PA-C (NPI 1609321074)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609321074 NPI number — MRS. TARA L BOYLE PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOYLE
Provider First Name:
TARA
Provider Middle Name:
L
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PELLERITO
Provider Other First Name:
TARA
Provider Other Middle Name:
L
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA-C
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1609321074
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11350 MCCORMICK RD
Provider Second Line Business Mailing Address:
EXECUTIVE PLAZA 1, SUITE 501
Provider Business Mailing Address City Name:
HUNT VALLEY
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21031
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-329-1071
Provider Business Mailing Address Fax Number:
410-329-1054

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8 SAXON AVE STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BAY SHORE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11706-7036
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
631-206-1034
Provider Business Practice Location Address Fax Number:
631-206-1046
Provider Enumeration Date:
08/16/2016

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: 363A00000X , with the licence number:  019992-1 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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