Provider Demographics
NPI:1609910132
Name:ATHA, TARA RAE (MS, NP)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:RAE
Last Name:ATHA
Suffix:
Gender:F
Credentials:MS, NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 EMMANUEL WAY
Mailing Address - Street 2:STE B
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45502-7217
Mailing Address - Country:US
Mailing Address - Phone:937-398-0020
Mailing Address - Fax:937-398-0021
Practice Address - Street 1:2100 EMMANUEL WAY
Practice Address - Street 2:SUITE B
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45502-7217
Practice Address - Country:US
Practice Address - Phone:937-398-0020
Practice Address - Fax:937-398-0021
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-17
Last Update Date:2010-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHNP-09226363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2737953Medicaid
OHP00385789OtherRAILROAD PIN
OHNP22841Medicare PIN
OH2737953Medicaid