Provider Demographics
NPI:1245941145
Name:MOCKER, TARA MARIE
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:MARIE
Last Name:MOCKER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2324 E ROYAL CT
Mailing Address - Street 2:
Mailing Address - City:DES PERES
Mailing Address - State:MO
Mailing Address - Zip Code:63131-1941
Mailing Address - Country:US
Mailing Address - Phone:314-358-5874
Mailing Address - Fax:
Practice Address - Street 1:1050 WISHARD BLVD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-2872
Practice Address - Country:US
Practice Address - Phone:317-274-7447
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-12
Last Update Date:2022-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant