Provider Demographics
NPI:1902412463
Name:SHELLEY, TARA
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:SHELLEY
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 1:1345 AVENUE OF THE AMERICAS FL 8
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10105-0018
Mailing Address - Country:US
Mailing Address - Phone:908-588-3635
Mailing Address - Fax:914-457-1195
Practice Address - Street 1:210 WESTCHESTER AVE
Practice Address - Street 2:
Practice Address - City:WHITE PLAINS
Practice Address - State:NY
Practice Address - Zip Code:10604-2901
Practice Address - Country:US
Practice Address - Phone:914-682-6532
Practice Address - Fax:914-681-5260
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-21
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025548363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant