Provider Demographics
NPI:1316977192
Name:FARRAR, TASHA (MD)
Entity type:Individual
Prefix:
First Name:TASHA
Middle Name:
Last Name:FARRAR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:402 E PACIFIC ST
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54911-5069
Mailing Address - Country:US
Mailing Address - Phone:802-579-2252
Mailing Address - Fax:
Practice Address - Street 1:3301 N BALLARD RD STE C
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54911-9002
Practice Address - Country:US
Practice Address - Phone:920-841-8326
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2020-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT042-0011157103TB0200X, 2084P0800X
WI54559-0202084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI54559-020OtherSTATE LICENSE
VT042-0011157OtherSTATE LICENSE