Provider Demographics
NPI:1346394699
Name:DAVIS, TARA A (PA-C, ATC)
Entity type:Individual
Prefix:MS
First Name:TARA
Middle Name:A
Last Name:DAVIS
Suffix:
Gender:F
Credentials:PA-C, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:239 GLEN VIEW TER
Mailing Address - Street 2:
Mailing Address - City:ABINGDON
Mailing Address - State:MD
Mailing Address - Zip Code:21009-3114
Mailing Address - Country:US
Mailing Address - Phone:203-258-7023
Mailing Address - Fax:
Practice Address - Street 1:235 S 33RD ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-6322
Practice Address - Country:US
Practice Address - Phone:800-789-7366
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2022-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA00004852255A2300X
CT0001332255A2300X
PAMA064151363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer