Provider Demographics
NPI:1598170383
Name:ETTER, TARA (DO)
Entity Type:Individual
Prefix:DR
First Name:TARA
Middle Name:
Last Name:ETTER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1048 TERRACE DR
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:VA
Mailing Address - Zip Code:24354-4138
Mailing Address - Country:US
Mailing Address - Phone:276-783-1827
Mailing Address - Fax:276-783-2879
Practice Address - Street 1:1020 TERRACE DR
Practice Address - Street 2:SUITE 101
Practice Address - City:MARION
Practice Address - State:VA
Practice Address - Zip Code:24354-4392
Practice Address - Country:US
Practice Address - Phone:276-783-8183
Practice Address - Fax:276-782-9267
Is Sole Proprietor?:No
Enumeration Date:2014-06-30
Last Update Date:2017-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102204770208000000X
GA6907208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics