Provider Demographics
NPI:1528400629
Name:FISHBACK, TARA L (PA-C)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:L
Last Name:FISHBACK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:L
Other - Last Name:ELTA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1221 SIXTH ST STE 300
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-2360
Mailing Address - Country:US
Mailing Address - Phone:231-392-0640
Mailing Address - Fax:231-392-0643
Practice Address - Street 1:1221 SIXTH ST STE 300
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-2360
Practice Address - Country:US
Practice Address - Phone:231-392-0640
Practice Address - Fax:231-392-0643
Is Sole Proprietor?:No
Enumeration Date:2013-07-18
Last Update Date:2021-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5447363AM0700X
WI3747-23363AM0700X
MEPA1799363AM0700X
MI5601010328363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ832909Medicaid
AZZ160120Medicare PIN