Provider Demographics
NPI:1407973266
Name:DECRESCENTIS, TARA MENDOZZA (PA-C)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:MENDOZZA
Last Name:DECRESCENTIS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:
Other - Last Name:MENDOZZA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 172263
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80217-2263
Mailing Address - Country:US
Mailing Address - Phone:303-306-7783
Mailing Address - Fax:303-306-7753
Practice Address - Street 1:10099 RIDGEGATE PKWY STE 480
Practice Address - Street 2:
Practice Address - City:LONE TREE
Practice Address - State:CO
Practice Address - Zip Code:80124-5537
Practice Address - Country:US
Practice Address - Phone:720-441-4021
Practice Address - Fax:720-360-1195
Is Sole Proprietor?:No
Enumeration Date:2007-03-24
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2368363A00000X, 363AS0400X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO2368OtherLICENSE
Q78478Medicare UPIN