Provider Demographics
NPI:1104809342
Name:JERNEJCIC, TARA CARSON (PA-C)
Entity type:Individual
Prefix:MRS
First Name:TARA
Middle Name:CARSON
Last Name:JERNEJCIC
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4692 BROWNSBORO ROAD
Mailing Address - Street 2:
Mailing Address - City:WINSTON - SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27106
Mailing Address - Country:US
Mailing Address - Phone:336-251-1114
Mailing Address - Fax:336-251-1116
Practice Address - Street 1:100 SOUTH MARKET STREET
Practice Address - Street 2:FREDERICK COMMUNITY ACTION AGENCY
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21701
Practice Address - Country:US
Practice Address - Phone:301-600-1506
Practice Address - Fax:301-662-9079
Is Sole Proprietor?:No
Enumeration Date:2005-11-22
Last Update Date:2015-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC600122363AM0700X
NC102381363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2747507HMedicare ID - Type Unspecified
NCS57601Medicare UPIN