Provider Demographics
NPI:1578715637
Name:MANLY, TARA LAURINE (PA)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:LAURINE
Last Name:MANLY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 844658
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-4658
Mailing Address - Country:US
Mailing Address - Phone:254-724-2111
Mailing Address - Fax:
Practice Address - Street 1:2401 S 31ST ST
Practice Address - Street 2:6 WEST SPINE CENTER
Practice Address - City:TEMPLE
Practice Address - State:TX
Practice Address - Zip Code:76508-7196
Practice Address - Country:US
Practice Address - Phone:254-724-2111
Practice Address - Fax:254-724-7567
Is Sole Proprietor?:No
Enumeration Date:2008-10-21
Last Update Date:2022-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA06458363AM0700X, 363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical