Provider Demographics
NPI:1598835811
Name:SALLEY, TARA LYNN (PA-C)
Entity Type:Individual
Prefix:MS
First Name:TARA
Middle Name:LYNN
Last Name:SALLEY
Suffix:
Gender:F
Credentials:PA-C
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 70
Mailing Address - Street 2:
Mailing Address - City:LAME DEER
Mailing Address - State:MT
Mailing Address - Zip Code:59043-0070
Mailing Address - Country:US
Mailing Address - Phone:406-477-4484
Mailing Address - Fax:406-477-3153
Practice Address - Street 1:100 CHEYENNE AVE
Practice Address - Street 2:
Practice Address - City:LAME DEER
Practice Address - State:MT
Practice Address - Zip Code:59043-0070
Practice Address - Country:US
Practice Address - Phone:406-477-4484
Practice Address - Fax:406-477-3153
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2013-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT480363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant