Provider Demographics
NPI:1013994458
Name:LINVILLE, TARA (PA-C)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:LINVILLE
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 1:6600 S YALE AVE STE 1200
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-3361
Mailing Address - Country:US
Mailing Address - Phone:918-488-6045
Mailing Address - Fax:918-488-6098
Practice Address - Street 1:6565 S YALE AVE STE 1200
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136
Practice Address - Country:US
Practice Address - Phone:918-502-3376
Practice Address - Fax:918-502-3375
Is Sole Proprietor?:No
Enumeration Date:2005-12-28
Last Update Date:2018-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1108363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200060190AMedicaid
OK200060190AMedicaid
OK243526402Medicare ID - Type Unspecified