Provider Demographics
NPI:1114680808
Name:GROGAN, TARA LORD (CRNP)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:LORD
Last Name:GROGAN
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:PATRICE
Other - Last Name:LORD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3400 CIVIC CENTER BLVD FL 3
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-5127
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3400 CIVIC CENTER BLVD FL 3
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-5127
Practice Address - Country:US
Practice Address - Phone:215-316-5151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-19
Last Update Date:2021-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP024598363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner