Provider Demographics
NPI:1083844302
Name:RICHARDS, TARA L (PA)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:L
Last Name:RICHARDS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:L
Other - Last Name:TUTWILER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:5500 MAIN ST
Mailing Address - Street 2:SUITE 107
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-6755
Mailing Address - Country:US
Mailing Address - Phone:716-204-3200
Mailing Address - Fax:716-204-4061
Practice Address - Street 1:160 FARBER HALL
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14214-8001
Practice Address - Country:US
Practice Address - Phone:716-829-2070
Practice Address - Fax:716-829-2138
Is Sole Proprietor?:No
Enumeration Date:2009-07-21
Last Update Date:2012-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013298363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant