Provider Demographics
NPI:1346592615
Name:STEWART, TARA MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:MARIE
Last Name:STEWART
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:MARIE
Other - Last Name:HODGE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11521 N RANCH ROAD 620 STE 100
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78726-1112
Mailing Address - Country:US
Mailing Address - Phone:512-402-6830
Mailing Address - Fax:
Practice Address - Street 1:11521 N RANCH ROAD 620 STE 100
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78726-1112
Practice Address - Country:US
Practice Address - Phone:512-402-6830
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-10
Last Update Date:2020-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC04875363A00000X
TXPA09071363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant