Provider Demographics
NPI:1417540287
Name:JUDGE, TARA (PA-C)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:JUDGE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:95 POPLAR ST
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:PA
Mailing Address - Zip Code:18704-2809
Mailing Address - Country:US
Mailing Address - Phone:570-328-4165
Mailing Address - Fax:
Practice Address - Street 1:95 POPLAR ST
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:PA
Practice Address - Zip Code:18704-2809
Practice Address - Country:US
Practice Address - Phone:570-328-4165
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-12
Last Update Date:2021-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA062166363A00000X
PAOA005449363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant