Provider Demographics
NPI:1760660070
Name:WEATHERS, TARA A (NP)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:A
Last Name:WEATHERS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:A
Other - Last Name:WEATHERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 785377
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19178-5377
Mailing Address - Country:US
Mailing Address - Phone:203-688-6743
Mailing Address - Fax:
Practice Address - Street 1:593 EDDY ST
Practice Address - Street 2:CLAVERICK 2
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02903-4923
Practice Address - Country:US
Practice Address - Phone:401-444-5175
Practice Address - Fax:401-444-8874
Is Sole Proprietor?:No
Enumeration Date:2008-02-08
Last Update Date:2020-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT8686363LF0000X
RIAPRN00110363LF0000X
RINPP37450363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI0070601881OtherRI MEDICARE
RI939025129OtherRI MEDICARE UEMF GROUP PROVIDER
RITW69699Medicaid
RI06/10/2008OtherBCBS
MA718882Medicaid
RI05/08/2008OtherNHPRI