Provider Demographics
NPI:1255645339
Name:VUCHENICH, TARA D (PA-C MPAS)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:D
Last Name:VUCHENICH
Suffix:
Gender:F
Credentials:PA-C MPAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6983 HILLSDALE CT
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2054
Mailing Address - Country:US
Mailing Address - Phone:317-849-8350
Mailing Address - Fax:317-576-6311
Practice Address - Street 1:7250 CLEARVISTA DR STE 225
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46256-5626
Practice Address - Country:US
Practice Address - Phone:317-537-6088
Practice Address - Fax:317-537-6092
Is Sole Proprietor?:No
Enumeration Date:2010-08-02
Last Update Date:2021-03-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN10001190A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300005428Medicaid
INM400023837Medicare PIN
INP01209639OtherRR MEDICARE PTAN