Provider Demographics
NPI:1205296191
Name:SWAN, TARA (OPTICIAN)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:SWAN
Suffix:
Gender:F
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1815 STATE ST
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-9407
Mailing Address - Country:US
Mailing Address - Phone:315-786-8064
Mailing Address - Fax:315-788-1950
Practice Address - Street 1:1815 STATE ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-9407
Practice Address - Country:US
Practice Address - Phone:315-786-8064
Practice Address - Fax:315-788-1950
Is Sole Proprietor?:No
Enumeration Date:2016-03-04
Last Update Date:2016-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009466156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician