Provider Demographics
NPI:1558611491
Name:WAY, TARA MELISSA (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:TARA
Middle Name:MELISSA
Last Name:WAY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MRS
Other - First Name:TARA
Other - Middle Name:M
Other - Last Name:WAY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA-C
Mailing Address - Street 1:34841 VETERANS PLZ
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:MI
Mailing Address - Zip Code:48184-1733
Mailing Address - Country:US
Mailing Address - Phone:734-728-3446
Mailing Address - Fax:
Practice Address - Street 1:34841 VETERANS PLZ
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:MI
Practice Address - Zip Code:48184-1733
Practice Address - Country:US
Practice Address - Phone:734-728-3446
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-18
Last Update Date:2014-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant