Provider Demographics
NPI:1922732114
Name:CORNELL, TARA M (NPP)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:M
Last Name:CORNELL
Suffix:
Gender:M
Credentials:NPP
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:
Other - Last Name:MCCARRON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9 CAREY RD
Mailing Address - Street 2:
Mailing Address - City:QUEENSBURY
Mailing Address - State:NY
Mailing Address - Zip Code:12804-7880
Mailing Address - Country:US
Mailing Address - Phone:518-761-0300
Mailing Address - Fax:518-824-2388
Practice Address - Street 1:48 EAST ST
Practice Address - Street 2:
Practice Address - City:FORT EDWARD
Practice Address - State:NY
Practice Address - Zip Code:12828-1811
Practice Address - Country:US
Practice Address - Phone:518-824-8630
Practice Address - Fax:518-824-2302
Is Sole Proprietor?:No
Enumeration Date:2022-07-13
Last Update Date:2022-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF404226363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health