Provider Demographics
NPI:1922238831
Name:BERTZYK, TARAH R (PA)
Entity Type:Individual
Prefix:MS
First Name:TARAH
Middle Name:R
Last Name:BERTZYK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 S RANCH HOUSE RD
Mailing Address - Street 2:
Mailing Address - City:WILLOW PARK
Mailing Address - State:TX
Mailing Address - Zip Code:76008-2649
Mailing Address - Country:US
Mailing Address - Phone:817-984-7120
Mailing Address - Fax:817-984-7121
Practice Address - Street 1:123 S RANCH HOUSE RD
Practice Address - Street 2:
Practice Address - City:WILLOW PARK
Practice Address - State:TX
Practice Address - Zip Code:76008-2649
Practice Address - Country:US
Practice Address - Phone:817-984-7120
Practice Address - Fax:817-984-7121
Is Sole Proprietor?:No
Enumeration Date:2009-07-27
Last Update Date:2015-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA06239207PE0004X, 207Q00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX390958ZMEGOtherMEDICARE PTAN