Provider Demographics
NPI:1083027924
Name:CARTER, TATAYANA (PA-C)
Entity type:Individual
Prefix:
First Name:TATAYANA
Middle Name:
Last Name:CARTER
Suffix:
Gender:
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 1:5901 E FOWLER AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:TEMPLE TERRACE
Mailing Address - State:FL
Mailing Address - Zip Code:33617-2305
Mailing Address - Country:US
Mailing Address - Phone:813-978-9700
Mailing Address - Fax:813-558-6186
Practice Address - Street 1:560 S LAKEWOOD DR STE 101
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-5015
Practice Address - Country:US
Practice Address - Phone:813-978-9700
Practice Address - Fax:813-558-6186
Is Sole Proprietor?:No
Enumeration Date:2014-06-09
Last Update Date:2025-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9107942363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLMA684OtherMEDICARE PIN
FL018115900Medicaid
FLBF7VQOtherBC/BS OF FLORIDA
FLPA9107942OtherLICENSE
FL8889858OtherCIGNA/GREAT WEST
FLIG923ZMedicare PIN