Provider Demographics
NPI:1114462728
Name:O'DONNELL, TARRAH (PA-C)
Entity Type:Individual
Prefix:
First Name:TARRAH
Middle Name:
Last Name:O'DONNELL
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 1:120 SWEETBRIAR BR
Mailing Address - Street 2:
Mailing Address - City:LONGWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:32750-2715
Mailing Address - Country:US
Mailing Address - Phone:407-923-5052
Mailing Address - Fax:
Practice Address - Street 1:737 N MICHIGAN AVE STE 2270
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2680
Practice Address - Country:US
Practice Address - Phone:844-432-1900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-05
Last Update Date:2020-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9110094363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant