Provider Demographics
NPI:1063714046
Name:MOORE, TARA THOMPSON
Entity type:Individual
Prefix:MRS
First Name:TARA
Middle Name:THOMPSON
Last Name:MOORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:426 GA HIGHWAY 26 E
Mailing Address - Street 2:
Mailing Address - City:COCHRAN
Mailing Address - State:GA
Mailing Address - Zip Code:31014-2837
Mailing Address - Country:US
Mailing Address - Phone:478-934-2874
Mailing Address - Fax:478-934-2876
Practice Address - Street 1:426 GA HIGHWAY 26 E
Practice Address - Street 2:
Practice Address - City:COCHRAN
Practice Address - State:GA
Practice Address - Zip Code:31014-2837
Practice Address - Country:US
Practice Address - Phone:478-934-2874
Practice Address - Fax:478-934-2876
Is Sole Proprietor?:No
Enumeration Date:2010-11-24
Last Update Date:2010-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN164184363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily