Provider Demographics
NPI:1013279348
Name:GRIFFIN, TARA (PA-C)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:GRIFFIN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1711 S EXTENSION RD APT 2064
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85210-9518
Mailing Address - Country:US
Mailing Address - Phone:928-242-7834
Mailing Address - Fax:
Practice Address - Street 1:1711 S EXTENSION RD APT 2064
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85210
Practice Address - Country:US
Practice Address - Phone:928-242-7834
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-12
Last Update Date:2019-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7647363A00000X
AZ6682A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant