Provider Demographics
NPI:1376001891
Name:KLEIN, TARA
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:KLEIN
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 1:20401 W TERRACE LN
Mailing Address - Street 2:
Mailing Address - City:BUCKEYE
Mailing Address - State:AZ
Mailing Address - Zip Code:85396-7732
Mailing Address - Country:US
Mailing Address - Phone:920-912-3460
Mailing Address - Fax:
Practice Address - Street 1:19636 N 27TH AVE STE 408
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85027-4021
Practice Address - Country:US
Practice Address - Phone:623-780-0100
Practice Address - Fax:623-492-9160
Is Sole Proprietor?:No
Enumeration Date:2019-03-04
Last Update Date:2019-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZF06181686363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily