Provider Demographics
NPI:1104102920
Name:CORSO, TARA N (PA-C)
Entity type:Individual
Prefix:MRS
First Name:TARA
Middle Name:N
Last Name:CORSO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:TARA
Other - Middle Name:E
Other - Last Name:NEALON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:525 E 68TH STREET
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10065
Mailing Address - Country:US
Mailing Address - Phone:212-746-5454
Mailing Address - Fax:
Practice Address - Street 1:525 E 68TH STREET
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10065
Practice Address - Country:US
Practice Address - Phone:212-746-5454
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-25
Last Update Date:2019-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015258363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant