Provider Demographics
NPI:1013027416
Name:WILSON, TARA
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21311 W 51ST ST
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE
Mailing Address - State:KS
Mailing Address - Zip Code:66218-9089
Mailing Address - Country:US
Mailing Address - Phone:913-271-3833
Mailing Address - Fax:
Practice Address - Street 1:1333 MEADOWLARK LN
Practice Address - Street 2:STE 104
Practice Address - City:KANSAS CITY
Practice Address - State:KS
Practice Address - Zip Code:66102-1260
Practice Address - Country:US
Practice Address - Phone:913-287-9303
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS14-01634OtherLICENSE#