Provider Demographics
NPI:1982610150
Name:SPIVEY, TARA ROBERTS (PA-C, MPAS)
Entity Type:Individual
Prefix:MRS
First Name:TARA
Middle Name:ROBERTS
Last Name:SPIVEY
Suffix:
Gender:F
Credentials:PA-C, MPAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2109
Mailing Address - Street 2:
Mailing Address - City:DOUGLAS
Mailing Address - State:GA
Mailing Address - Zip Code:31534-2109
Mailing Address - Country:US
Mailing Address - Phone:912-384-6276
Mailing Address - Fax:912-389-1618
Practice Address - Street 1:1400 PETERSON AVE N STE C
Practice Address - Street 2:
Practice Address - City:DOUGLAS
Practice Address - State:GA
Practice Address - Zip Code:31533-2833
Practice Address - Country:US
Practice Address - Phone:912-384-6276
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2024-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003767363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA791479760AMedicaid
GA791479760AMedicaid
GA97WCHGKMedicare PIN