Provider Demographics
NPI:1366020794
Name:BLUNT, TARA ALEXANDRA
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:ALEXANDRA
Last Name:BLUNT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1714 W SATINWOOD DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85045-0517
Mailing Address - Country:US
Mailing Address - Phone:480-216-6665
Mailing Address - Fax:
Practice Address - Street 1:6601 W THOMAS RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85033-5700
Practice Address - Country:US
Practice Address - Phone:602-243-7277
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-29
Last Update Date:2023-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ9537363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant