1942697792 NPI number — MISS TARA ANDREA PROVIDENCE MD

Table of content: MISS TARA ANDREA PROVIDENCE MD (NPI 1942697792)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942697792 NPI number — MISS TARA ANDREA PROVIDENCE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PROVIDENCE
Provider First Name:
TARA
Provider Middle Name:
ANDREA
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1942697792
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/23/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
462 GRIDER ST
Provider Second Line Business Mailing Address:
DAVID K. MILLER BLDG.
Provider Business Mailing Address City Name:
BUFFALO
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14215
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
716-898-4578
Provider Business Mailing Address Fax Number:
716-898-3279

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
462 GRIDER ST.
Provider Second Line Business Practice Location Address:
DAVID K. MILLER BLDG.
Provider Business Practice Location Address City Name:
BUFFALO
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14215
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
716-898-4578
Provider Business Practice Location Address Fax Number:
716-898-3279
Provider Enumeration Date:
04/20/2015

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: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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