Provider Demographics
NPI:1780651661
Name:CUTLER, TARA LYNN (PAC)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:LYNN
Last Name:CUTLER
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7339
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78713-7339
Mailing Address - Country:US
Mailing Address - Phone:512-475-6635
Mailing Address - Fax:512-471-0680
Practice Address - Street 1:100 E DEAN KEETON ST
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78712-1043
Practice Address - Country:US
Practice Address - Phone:512-475-6635
Practice Address - Fax:512-471-0680
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-01
Last Update Date:2013-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA04915363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1005021699100502170Medicaid
Q07523Medicare UPIN
NV38529Medicare ID - Type Unspecified