Provider Demographics
NPI:1043286933
Name:ROA, TARA (PA)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:ROA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2214 CANTERBURY DR
Mailing Address - Street 2:SUITE 202
Mailing Address - City:HAYS
Mailing Address - State:KS
Mailing Address - Zip Code:67601-2375
Mailing Address - Country:US
Mailing Address - Phone:785-623-2312
Mailing Address - Fax:785-623-2323
Practice Address - Street 1:2214 CANTERBURY DR
Practice Address - Street 2:SUITE 202
Practice Address - City:HAYS
Practice Address - State:KS
Practice Address - Zip Code:67601-2375
Practice Address - Country:US
Practice Address - Phone:785-623-2312
Practice Address - Fax:785-623-2323
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS15-00907363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS042025Medicare ID - Type UnspecifiedINDIVIDUAL MEDICARE #
KSP98909Medicare UPIN