Provider Demographics
NPI:1003975129
Name:GILL, TARA MARIE (DC)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:MARIE
Last Name:GILL
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:MARIE
Other - Last Name:PAQUETTE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:N35W23770 CAPITOL DR
Mailing Address - Street 2:
Mailing Address - City:PEWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53072-6312
Mailing Address - Country:US
Mailing Address - Phone:262-695-1870
Mailing Address - Fax:262-695-1872
Practice Address - Street 1:N35W23770 CAPITOL DR
Practice Address - Street 2:
Practice Address - City:PEWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53072-6312
Practice Address - Country:US
Practice Address - Phone:262-695-1870
Practice Address - Fax:262-695-1872
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4098111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38961000Medicaid
V05278Medicare UPIN