Provider Demographics
NPI:1669622841
Name:PATRICK, TARA L (NP)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:L
Last Name:PATRICK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:L
Other - Last Name:LASLOVICH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:PO BOX 7609
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59807-7609
Mailing Address - Country:US
Mailing Address - Phone:406-721-5600
Mailing Address - Fax:
Practice Address - Street 1:2835 FORT MISSOULA RD
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59804-7423
Practice Address - Country:US
Practice Address - Phone:406-721-5600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-24
Last Update Date:2016-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT25016363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics