Provider Demographics
NPI:1982833026
Name:MANIERRE, TARA KRISTINE (PA)
Entity Type:Individual
Prefix:MS
First Name:TARA
Middle Name:KRISTINE
Last Name:MANIERRE
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 1:43 NEW SCOTLAND AVE
Mailing Address - Street 2:MAIL CODE - 73
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12208-3412
Mailing Address - Country:US
Mailing Address - Phone:518-262-3494
Mailing Address - Fax:
Practice Address - Street 1:43 NEW SCOTLAND AVE
Practice Address - Street 2:MAIL CODE - 73
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12208-3412
Practice Address - Country:US
Practice Address - Phone:518-262-3494
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-10
Last Update Date:2016-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013364363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical