Provider Demographics
NPI:1265723522
Name:LUYSTER, TARA N (PA-C)
Entity type:Individual
Prefix:MRS
First Name:TARA
Middle Name:N
Last Name:LUYSTER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:TARA
Other - Middle Name:N
Other - Last Name:GIBNEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1 HEALTHY WAY
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11572-1551
Mailing Address - Country:US
Mailing Address - Phone:516-632-3000
Mailing Address - Fax:
Practice Address - Street 1:3219 E TREMONT AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10461-5751
Practice Address - Country:US
Practice Address - Phone:718-792-8115
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-21
Last Update Date:2024-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00447500363A00000X
RIPA00591363A00000X
NY014723363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI0021424OtherMEDICARE PTAN
RITG84594Medicaid