Provider Demographics
NPI:1548569890
Name:KERSTEN, TARA A (MD)
Entity Type:Individual
Prefix:DR
First Name:TARA
Middle Name:A
Last Name:KERSTEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:A
Other - Last Name:MENCIAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2901 W KINNICKINNIC RIVER PKWY
Mailing Address - Street 2:SUITE 106
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-3677
Mailing Address - Country:US
Mailing Address - Phone:414-649-7708
Mailing Address - Fax:414-649-7028
Practice Address - Street 1:2901 W KINNICKINNIC RIVER PKWY
Practice Address - Street 2:SUITE 106
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53215-3677
Practice Address - Country:US
Practice Address - Phone:414-649-7708
Practice Address - Fax:414-649-7028
Is Sole Proprietor?:No
Enumeration Date:2011-03-24
Last Update Date:2021-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IA42462208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program