Provider Demographics
NPI:1437438850
Name:RILEY, TARA N (PA)
Entity Type:Individual
Prefix:MRS
First Name:TARA
Middle Name:N
Last Name:RILEY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
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Mailing Address - Street 1:6330 E 75TH STREET
Mailing Address - Street 2:SUITE 110
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2717
Mailing Address - Country:US
Mailing Address - Phone:317-588-7130
Mailing Address - Fax:
Practice Address - Street 1:6330 E 75TH STREET
Practice Address - Street 2:SUITE 110
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46250-2717
Practice Address - Country:US
Practice Address - Phone:317-588-7130
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-16
Last Update Date:2020-10-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN10001271A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300015640Medicaid