Provider Demographics
NPI:1306968482
Name:KAVANAUGH, TARA LYNN (PA-C)
Entity type:Individual
Prefix:MRS
First Name:TARA
Middle Name:LYNN
Last Name:KAVANAUGH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:LYNN
Other - Last Name:CORKERY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 3299
Mailing Address - Street 2:
Mailing Address - City:CARSON CITY
Mailing Address - State:NV
Mailing Address - Zip Code:89702-3299
Mailing Address - Country:US
Mailing Address - Phone:775-222-0042
Mailing Address - Fax:775-222-0056
Practice Address - Street 1:5505 S 900 E STE 240
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84117-7210
Practice Address - Country:US
Practice Address - Phone:801-783-5011
Practice Address - Fax:801-746-3734
Is Sole Proprietor?:No
Enumeration Date:2007-04-06
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPA1111363A00000X
MDC0003211363A00000X
UT10088016-1206363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDKL09Q876Medicare PIN