Provider Demographics
NPI:1821614991
Name:TRENHAILE, TARA K (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:K
Last Name:TRENHAILE
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
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 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-343-9646
Mailing Address - Fax:239-343-9681
Practice Address - Street 1:8960 COLONIAL CENTER DR STE 202
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33905-7810
Practice Address - Country:US
Practice Address - Phone:239-343-9646
Practice Address - Fax:239-343-9681
Is Sole Proprietor?:No
Enumeration Date:2020-06-24
Last Update Date:2022-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-10292363AM0700X
FLPA9115050363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL112702700Medicaid