Provider Demographics
NPI:1720174345
Name:WILSON, TARA L (MD)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:L
Last Name:WILSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:L
Other - Last Name:THOMAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 2828
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92878-2828
Mailing Address - Country:US
Mailing Address - Phone:951-278-8870
Mailing Address - Fax:951-278-8913
Practice Address - Street 1:3660 PARK SIERRA DR
Practice Address - Street 2:SUITE 105
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92505-3071
Practice Address - Country:US
Practice Address - Phone:951-278-8870
Practice Address - Fax:951-278-8913
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2021-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA80520208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery