Provider Demographics
NPI:1619968906
Name:VILLANO, TARA C (PA)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:C
Last Name:VILLANO
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 1:5000 COX RD
Mailing Address - Street 2:
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23060-9263
Mailing Address - Country:US
Mailing Address - Phone:804-965-8700
Mailing Address - Fax:
Practice Address - Street 1:47100 COMMUNITY PLZ
Practice Address - Street 2:
Practice Address - City:STERLING
Practice Address - State:VA
Practice Address - Zip Code:20164-1826
Practice Address - Country:US
Practice Address - Phone:703-880-1403
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-04
Last Update Date:2022-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCPA030369363A00000X
VA0110002514363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA005814995Medicaid
DC110184642OtherRAILROAD PALMETTO MEDICARE
VA005814995Medicaid
DC110184642OtherRAILROAD PALMETTO MEDICARE
VA328573YWAUMedicare PIN