Provider Demographics
NPI:1750567053
Name:VANDEWARKER, TARA (PA-C)
Entity type:Individual
Prefix:MRS
First Name:TARA
Middle Name:
Last Name:VANDEWARKER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5333 MCAULEY DR
Mailing Address - Street 2:STE R1018
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48197
Mailing Address - Country:US
Mailing Address - Phone:734-434-3007
Mailing Address - Fax:734-434-6212
Practice Address - Street 1:5333 MCAULEY DRIVE
Practice Address - Street 2:STE R1018
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197
Practice Address - Country:US
Practice Address - Phone:734-434-3007
Practice Address - Fax:734-434-6212
Is Sole Proprietor?:No
Enumeration Date:2008-01-16
Last Update Date:2008-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601005160363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical