Provider Demographics
NPI:1669024212
Name:MYATT, TARA ALEXANDRIA
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:ALEXANDRIA
Last Name:MYATT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3115 S SPRING CREEK LN
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99224-9612
Mailing Address - Country:US
Mailing Address - Phone:310-971-3175
Mailing Address - Fax:
Practice Address - Street 1:3115 S SPRING CREEK LN
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99224-9612
Practice Address - Country:US
Practice Address - Phone:310-971-3175
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-14
Last Update Date:2019-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program