Provider Demographics
NPI:1003417551
Name:TABBAA, TARA (PA-C)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:TABBAA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6618 BRETTIN DR
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:OH
Mailing Address - Zip Code:44131-6541
Mailing Address - Country:US
Mailing Address - Phone:216-789-5753
Mailing Address - Fax:
Practice Address - Street 1:2570 SOM CENTER RD
Practice Address - Street 2:
Practice Address - City:WILLOUGHBY HILLS
Practice Address - State:OH
Practice Address - Zip Code:44094-9607
Practice Address - Country:US
Practice Address - Phone:440-943-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-02
Last Update Date:2021-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.007935207Q00000X
IL085-007935363A00000X
OH50.006628RX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine