Provider Demographics
NPI:1366854655
Name:PANDISCIA, TARA L (PT, DPT)
Entity Type:Individual
Prefix:MISS
First Name:TARA
Middle Name:L
Last Name:PANDISCIA
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2328 PAGE CV
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23451-1005
Mailing Address - Country:US
Mailing Address - Phone:252-412-5478
Mailing Address - Fax:
Practice Address - Street 1:1004 FIRST COLONIAL RD STE 101
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23454-3070
Practice Address - Country:US
Practice Address - Phone:757-578-2958
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-21
Last Update Date:2020-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP11731225100000X
VA2305213070225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist