Provider Demographics
NPI:1619120938
Name:MAHONEY, TARA (NP)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:MAHONEY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 TECHNOLOGY DR
Mailing Address - Street 2:
Mailing Address - City:EAST SETAUKET
Mailing Address - State:NY
Mailing Address - Zip Code:11733-4080
Mailing Address - Country:US
Mailing Address - Phone:631-444-4601
Mailing Address - Fax:631-444-4990
Practice Address - Street 1:4 TECHNOLOGY DR
Practice Address - Street 2:
Practice Address - City:EAST SETAUKET
Practice Address - State:NY
Practice Address - Zip Code:11733-4080
Practice Address - Country:US
Practice Address - Phone:631-444-4601
Practice Address - Fax:631-444-4990
Is Sole Proprietor?:No
Enumeration Date:2008-10-30
Last Update Date:2013-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF382012363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics