Provider Demographics
NPI:1164455689
Name:CLEMENS, TARA N (PA)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:N
Last Name:CLEMENS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 S ROLLIE AVE
Mailing Address - Street 2:
Mailing Address - City:FORT LUPTON
Mailing Address - State:CO
Mailing Address - Zip Code:80621-1508
Mailing Address - Country:US
Mailing Address - Phone:303-286-4560
Mailing Address - Fax:303-286-4589
Practice Address - Street 1:5995 IRIS PARKWAY
Practice Address - Street 2:BOX 189
Practice Address - City:FREDERICK
Practice Address - State:CO
Practice Address - Zip Code:80530
Practice Address - Country:US
Practice Address - Phone:303-833-2050
Practice Address - Fax:303-833-9183
Is Sole Proprietor?:No
Enumeration Date:2006-07-08
Last Update Date:2013-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0002098363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO85584541Medicaid
COC805890Medicare PIN