Provider Demographics
NPI:1114350691
Name:PERRY, TARA A (MED)
Entity Type:Individual
Prefix:MISS
First Name:TARA
Middle Name:A
Last Name:PERRY
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:449 E MOUNTAIN RIDGE MHP
Mailing Address - Street 2:
Mailing Address - City:WILKES BARRE
Mailing Address - State:PA
Mailing Address - Zip Code:18702-8037
Mailing Address - Country:US
Mailing Address - Phone:570-498-1234
Mailing Address - Fax:
Practice Address - Street 1:449 E MOUNTAIN RIDGE MHP
Practice Address - Street 2:
Practice Address - City:WILKES BARRE
Practice Address - State:PA
Practice Address - Zip Code:18702-8037
Practice Address - Country:US
Practice Address - Phone:570-498-1234
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-19
Last Update Date:2020-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist