1760629943 NPI number — ALISHA CORA TARTER WILSON PA-C

Table of content: ALISHA CORA TARTER WILSON PA-C (NPI 1760629943)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760629943 NPI number — ALISHA CORA TARTER WILSON PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TARTER WILSON
Provider First Name:
ALISHA
Provider Middle Name:
CORA
Provider Name Prefix Text:
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:
TARTER
Provider Other First Name:
ALISHA
Provider Other Middle Name:
CORA
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1760629943
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/28/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 719
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOMERSET
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
42502-0719
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
606-451-0485
Provider Business Mailing Address Fax Number:
606-451-0229

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
30 MEDPARK SQUARE
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
SOMERSET
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42503-3812
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-451-0485
Provider Business Practice Location Address Fax Number:
606-451-0229
Provider Enumeration Date:
01/09/2009

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: 363AS0400X , with the licence number:  PA1163 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: PA1163 . This is a "KY LICENSE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".




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