Provider Demographics
NPI:1639313745
Name:KRISHNASASTRY, TARA (PA)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:KRISHNASASTRY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:11220 72ND DR APT C02
Mailing Address - Street 2:
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-5649
Mailing Address - Country:US
Mailing Address - Phone:516-232-3455
Mailing Address - Fax:
Practice Address - Street 1:24411 HEALTH CENTER DR STE 680
Practice Address - Street 2:
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-3692
Practice Address - Country:US
Practice Address - Phone:949-268-4568
Practice Address - Fax:954-337-0760
Is Sole Proprietor?:No
Enumeration Date:2009-04-21
Last Update Date:2024-02-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAPA64005363A00000X
NY013169363A00000X
CT5352363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant