Provider Demographics
NPI:1295710952
Name:LOUKA, TARA D (PA)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:D
Last Name:LOUKA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:7101 JAHNKE ROAD
Mailing Address - Street 2:SUITE 550
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23225
Mailing Address - Country:US
Mailing Address - Phone:804-560-8880
Mailing Address - Fax:804-560-9577
Practice Address - Street 1:350 7TH ST N
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34102-5754
Practice Address - Country:US
Practice Address - Phone:239-624-4200
Practice Address - Fax:239-624-4241
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-14
Last Update Date:2020-02-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLPA9111974363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLEJBOZOtherBCBS
FL103234900Medicaid