Provider Demographics
NPI:1760469944
Name:HERBERT, TARA M (PA C)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:M
Last Name:HERBERT
Suffix:
Gender:F
Credentials:PA C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:20 YORK ST
Mailing Address - Street 2:CB2041
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06510-3220
Mailing Address - Country:US
Mailing Address - Phone:203-688-4748
Mailing Address - Fax:203-688-4740
Practice Address - Street 1:20 YORK ST
Practice Address - Street 2:YNH MEDICAL SERVICES PC - CB 2041
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06510-3220
Practice Address - Country:US
Practice Address - Phone:203-688-4748
Practice Address - Fax:203-688-4740
Is Sole Proprietor?:No
Enumeration Date:2005-12-28
Last Update Date:2007-09-18
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CT000643363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
P14865Medicare UPIN