Provider Demographics
NPI:1679059505
Name:CARLESCO, TARA NICOLE (PA-C)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:NICOLE
Last Name:CARLESCO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10321 TOWN WALK DR # 10321
Mailing Address - Street 2:
Mailing Address - City:HAMDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06518-3721
Mailing Address - Country:US
Mailing Address - Phone:315-430-4042
Mailing Address - Fax:
Practice Address - Street 1:821 N MAIN STREET EXT STE 210
Practice Address - Street 2:
Practice Address - City:WALLINGFORD
Practice Address - State:CT
Practice Address - Zip Code:06492-2464
Practice Address - Country:US
Practice Address - Phone:203-294-3610
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-13
Last Update Date:2018-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT4160363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical