Provider Demographics
NPI:1093840605
Name:ZICKERMAN, TARA LYNN (PA)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:LYNN
Last Name:ZICKERMAN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:LYNN
Other - Last Name:CUNNINGHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 1048
Mailing Address - Street 2:
Mailing Address - City:PORT WASHINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11050-1048
Mailing Address - Country:US
Mailing Address - Phone:516-338-5300
Mailing Address - Fax:
Practice Address - Street 1:100 PORT WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:ROSLYN
Practice Address - State:NY
Practice Address - Zip Code:11576-1353
Practice Address - Country:US
Practice Address - Phone:516-338-5300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-22
Last Update Date:2009-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006110363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant