Provider Demographics
NPI:1104809342
Name:JERNEJCIC, TARA C (PA-C)
Entity type:Individual
Prefix:MRS
First Name:TARA
Middle Name:C
Last Name:JERNEJCIC
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 S CENTER ST
Mailing Address - Street 2:
Mailing Address - City:THURMONT
Mailing Address - State:MD
Mailing Address - Zip Code:21788-1945
Mailing Address - Country:US
Mailing Address - Phone:301-696-8801
Mailing Address - Fax:301-696-0186
Practice Address - Street 1:100 S CENTER ST
Practice Address - Street 2:
Practice Address - City:THURMONT
Practice Address - State:MD
Practice Address - Zip Code:21788-1945
Practice Address - Country:US
Practice Address - Phone:301-696-8801
Practice Address - Fax:301-696-0186
Is Sole Proprietor?:No
Enumeration Date:2005-11-22
Last Update Date:2025-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC005418363AM0700X
NC102381363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2747507HMedicare ID - Type Unspecified
NCS57601Medicare UPIN