Provider Demographics
NPI:1215381108
Name:MILES, TARA SHAJUAN (FNP)
Entity Type:Individual
Prefix:MS
First Name:TARA
Middle Name:SHAJUAN
Last Name:MILES
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 BOXWOOD LN
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:SC
Mailing Address - Zip Code:29621-7300
Mailing Address - Country:US
Mailing Address - Phone:864-221-9352
Mailing Address - Fax:
Practice Address - Street 1:545 W BUTLER RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29607-4833
Practice Address - Country:US
Practice Address - Phone:864-299-1990
Practice Address - Fax:864-299-9123
Is Sole Proprietor?:No
Enumeration Date:2016-04-18
Last Update Date:2016-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC19424363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC19424OtherSTATE LICENSE