Provider Demographics
NPI:1164733101
Name:VAIL, TARA ELAINE (PA)
Entity Type:Individual
Prefix:MISS
First Name:TARA
Middle Name:ELAINE
Last Name:VAIL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:501 6TH AVE S
Mailing Address - Street 2:DEPT #6580070408
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33701-4634
Mailing Address - Country:US
Mailing Address - Phone:727-767-8480
Mailing Address - Fax:727-767-8420
Practice Address - Street 1:501 6TH AVE S
Practice Address - Street 2:DEPT #6580070408
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33701-4634
Practice Address - Country:US
Practice Address - Phone:727-767-8480
Practice Address - Fax:727-767-8420
Is Sole Proprietor?:No
Enumeration Date:2010-06-24
Last Update Date:2016-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9105507363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL002525300Medicaid