Provider Demographics
NPI:1467822320
Name:HUMPHREYS, TARA D (LAT, ATC)
Entity Type:Individual
Prefix:MRS
First Name:TARA
Middle Name:D
Last Name:HUMPHREYS
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12345 E LEGAL TENDER RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:IN
Mailing Address - Zip Code:47203-9424
Mailing Address - Country:US
Mailing Address - Phone:812-350-7495
Mailing Address - Fax:
Practice Address - Street 1:275 W BASSETT RD
Practice Address - Street 2:
Practice Address - City:SHELBYVILLE
Practice Address - State:IN
Practice Address - Zip Code:46176-8574
Practice Address - Country:US
Practice Address - Phone:317-392-2161
Practice Address - Fax:317-398-1870
Is Sole Proprietor?:No
Enumeration Date:2015-10-03
Last Update Date:2015-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36001308A207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine