Provider Demographics
NPI:1215276548
Name:FERGUSON, TARA M (DOCTORATE OF PHYSICA)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:M
Last Name:FERGUSON
Suffix:
Gender:F
Credentials:DOCTORATE OF PHYSICA
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:
Other - Last Name:MINKUS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DOCTORATE OF PHYSICA
Mailing Address - Street 1:625 LINCOLN AVE
Mailing Address - Street 2:SUITE 209
Mailing Address - City:NORTH CHARLEROI
Mailing Address - State:PA
Mailing Address - Zip Code:15022-2451
Mailing Address - Country:US
Mailing Address - Phone:724-483-3610
Mailing Address - Fax:724-489-4758
Practice Address - Street 1:605 SCENERY DRIVE
Practice Address - Street 2:
Practice Address - City:ELIZABETH
Practice Address - State:PA
Practice Address - Zip Code:15037-2000
Practice Address - Country:US
Practice Address - Phone:412-751-0040
Practice Address - Fax:412-751-0041
Is Sole Proprietor?:No
Enumeration Date:2013-02-06
Last Update Date:2016-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT022583225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1027971610001Medicaid
PA1027971610001Medicaid