Provider Demographics
NPI:1255812129
Name:SPALDING, TARA E (PA-C)
Entity type:Individual
Prefix:MRS
First Name:TARA
Middle Name:E
Last Name:SPALDING
Suffix:
Gender:
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 1:4374 NEW TOWN AVE
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23188-2865
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11803 JEFFERSON AVE STE 230
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23606-4390
Practice Address - Country:US
Practice Address - Phone:757-534-7701
Practice Address - Fax:757-534-7708
Is Sole Proprietor?:No
Enumeration Date:2018-08-28
Last Update Date:2025-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10002506A363A00000X
VA0110007328363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300027406Medicaid