Provider Demographics
NPI:1770579146
Name:DALTON, TARA LEE (PA C)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:LEE
Last Name:DALTON
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 1:300 W 1400 S
Mailing Address - Street 2:
Mailing Address - City:GARLAND
Mailing Address - State:UT
Mailing Address - Zip Code:84312-9393
Mailing Address - Country:US
Mailing Address - Phone:435-257-2469
Mailing Address - Fax:435-257-2434
Practice Address - Street 1:300 W 1400 S
Practice Address - Street 2:
Practice Address - City:GARLAND
Practice Address - State:UT
Practice Address - Zip Code:84312-9393
Practice Address - Country:US
Practice Address - Phone:435-257-2469
Practice Address - Fax:435-257-2434
Is Sole Proprietor?:No
Enumeration Date:2005-09-21
Last Update Date:2007-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT51994251206363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT005560504Medicare PIN
Q53274Medicare UPIN