Provider Demographics
NPI:1649494691
Name:PRIDE, TAMARA A (PA-C)
Entity type:Individual
Prefix:MISS
First Name:TAMARA
Middle Name:A
Last Name:PRIDE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:820 E TERRA COTTA AVE
Mailing Address - Street 2:STE 125
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60014-3650
Mailing Address - Country:US
Mailing Address - Phone:847-842-8839
Mailing Address - Fax:847-392-8439
Practice Address - Street 1:820 E TERRA COTTA AVE STE 125
Practice Address - Street 2:
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014
Practice Address - Country:US
Practice Address - Phone:815-455-4434
Practice Address - Fax:815-455-4593
Is Sole Proprietor?:No
Enumeration Date:2007-04-12
Last Update Date:2018-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085001795363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK17642Medicare UPIN