Provider Demographics
NPI:1881231926
Name:EDERSHEIM, TARA JEAN
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:JEAN
Last Name:EDERSHEIM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 E GENESEE ST STE 1
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:NY
Mailing Address - Zip Code:13021-4068
Mailing Address - Country:US
Mailing Address - Phone:315-253-9795
Mailing Address - Fax:
Practice Address - Street 1:17 E GENESEE ST STE 1
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:NY
Practice Address - Zip Code:13021-4068
Practice Address - Country:US
Practice Address - Phone:315-253-9795
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-09
Last Update Date:2019-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY301264164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY301264OtherLPN