Provider Demographics
NPI:1558393751
Name:WALKER, TARA (DA)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:WALKER
Suffix:
Gender:F
Credentials:DA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14155 N 83RD AVE
Mailing Address - Street 2:SUITE #110
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85381-5639
Mailing Address - Country:US
Mailing Address - Phone:623-215-0911
Mailing Address - Fax:623-215-0912
Practice Address - Street 1:14155 N 83RD AVE
Practice Address - Street 2:SUITE #110
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381-5639
Practice Address - Country:US
Practice Address - Phone:623-215-0911
Practice Address - Fax:623-215-0912
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2009-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA04688364SP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
8G2574Medicare ID - Type Unspecified
Q60017Medicare UPIN