Provider Demographics
NPI:1306490396
Name:DESO, TARA L (NP)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:L
Last Name:DESO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:L
Other - Last Name:MCCUE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5 NEPONSET ST
Mailing Address - Street 2:WOT 2ND FL, STE C203
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01606-2714
Mailing Address - Country:US
Mailing Address - Phone:508-595-2000
Mailing Address - Fax:508-853-7149
Practice Address - Street 1:385 GROVE ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01605-3924
Practice Address - Country:US
Practice Address - Phone:508-595-2000
Practice Address - Fax:508-853-7149
Is Sole Proprietor?:No
Enumeration Date:2019-07-29
Last Update Date:2020-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN284675363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110158765AMedicaid