Provider Demographics
NPI:1154728442
Name:IRVIN, TARA (CRNP)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:IRVIN
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:785 5TH AVE STE 3
Mailing Address - Street 2:
Mailing Address - City:CHAMBERSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17201-4232
Mailing Address - Country:US
Mailing Address - Phone:717-263-9555
Mailing Address - Fax:717-217-4218
Practice Address - Street 1:12 ST PAUL DR STE 210
Practice Address - Street 2:
Practice Address - City:CHAMBERSBURG
Practice Address - State:PA
Practice Address - Zip Code:17201-1035
Practice Address - Country:US
Practice Address - Phone:717-217-6820
Practice Address - Fax:717-217-6942
Is Sole Proprietor?:No
Enumeration Date:2014-12-02
Last Update Date:2020-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP014167363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102995936Medicaid
PA102995936Medicaid