Provider Demographics
NPI:1457439481
Name:SHEA, TARA
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:SHEA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:
Other - Last Name:MCGILL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2050 N HAGGERTY RD STE 260
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48187-3796
Mailing Address - Country:US
Mailing Address - Phone:734-981-1086
Mailing Address - Fax:734-981-5094
Practice Address - Street 1:2050 N HAGGERTY RD
Practice Address - Street 2:SUITE 100
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48187-3795
Practice Address - Country:US
Practice Address - Phone:734-981-7086
Practice Address - Fax:734-981-5094
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2019-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704201117363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily