Provider Demographics
NPI:1245246180
Name:LONGORIA, TARA ANN (MD)
Entity Type:Individual
Prefix:DR
First Name:TARA
Middle Name:ANN
Last Name:LONGORIA
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:18 SITZMAN CT
Mailing Address - Street 2:
Mailing Address - City:SCOTTSBLUFF
Mailing Address - State:NE
Mailing Address - Zip Code:69361-4697
Mailing Address - Country:US
Mailing Address - Phone:308-632-6310
Mailing Address - Fax:308-630-2113
Practice Address - Street 1:3911 AVENUE B
Practice Address - Street 2:SUITE 1100
Practice Address - City:SCOTTSBLUFF
Practice Address - State:NE
Practice Address - Zip Code:69361-4617
Practice Address - Country:US
Practice Address - Phone:308-630-2100
Practice Address - Fax:308-630-2113
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2014-02-10
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Provider Licenses
StateLicense IDTaxonomies
NE470788581207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
080165023OtherPALMENTO GBA RR MEDICARE
NEH24237Medicare UPIN
NE272952Medicare UPIN