Provider Demographics
NPI:1760629943
Name:TARTER WILSON, ALISHA CORA (PA-C)
Entity Type:Individual
Prefix:
First Name:ALISHA
Middle Name:CORA
Last Name:TARTER WILSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ALISHA
Other - Middle Name:CORA
Other - Last Name:TARTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 719
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:KY
Mailing Address - Zip Code:42502-0719
Mailing Address - Country:US
Mailing Address - Phone:606-451-0485
Mailing Address - Fax:606-451-0229
Practice Address - Street 1:30 MEDPARK SQUARE
Practice Address - Street 2:SUITE 1
Practice Address - City:SOMERSET
Practice Address - State:KY
Practice Address - Zip Code:42503-3812
Practice Address - Country:US
Practice Address - Phone:606-451-0485
Practice Address - Fax:606-451-0229
Is Sole Proprietor?:No
Enumeration Date:2009-01-09
Last Update Date:2016-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA1163363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYPA1163OtherKY LICENSE