Provider Demographics
NPI:1912087438
Name:ROTHWELL, TARA C (PA)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:C
Last Name:ROTHWELL
Suffix:
Gender:F
Credentials:PA
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Mailing Address - Street 1:PO BOX 191050
Mailing Address - Street 2:SUITE 115
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83719-1050
Mailing Address - Country:US
Mailing Address - Phone:208-955-6500
Mailing Address - Fax:208-955-6503
Practice Address - Street 1:6052 W STATE ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83703-2739
Practice Address - Country:US
Practice Address - Phone:208-344-7799
Practice Address - Fax:208-344-7152
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2023-01-04
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NVPA574363A00000X
IDPA669363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant