Provider Demographics
NPI:1518988211
Name:ANDRISIN, TARA M (PA)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:M
Last Name:ANDRISIN
Suffix:
Gender:F
Credentials:PA
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Mailing Address - Street 1:801 YORK ST
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-4630
Mailing Address - Country:US
Mailing Address - Phone:920-663-9008
Mailing Address - Fax:920-684-1439
Practice Address - Street 1:120 NW 76TH DR
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32607-6652
Practice Address - Country:US
Practice Address - Phone:352-333-3223
Practice Address - Fax:352-332-4550
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2020-12-10
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
FLPA9102874363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLQ48602Medicare PIN