Provider Demographics
NPI:1003134347
Name:WILSON, TARA JENE (LSA)
Entity Type:Individual
Prefix:MS
First Name:TARA
Middle Name:JENE
Last Name:WILSON
Suffix:
Gender:F
Credentials:LSA
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:9800 CENTRE PKWY
Mailing Address - Street 2:530
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77036-8271
Mailing Address - Country:US
Mailing Address - Phone:713-777-4539
Mailing Address - Fax:713-583-2061
Practice Address - Street 1:9800 CENTRE PKWY
Practice Address - Street 2:530
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77036-8271
Practice Address - Country:US
Practice Address - Phone:713-777-4539
Practice Address - Fax:713-583-2061
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-11
Last Update Date:2014-11-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXSA00516246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant