Provider Demographics
NPI:1386446292
Name:SHELBY, TARA
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:SHELBY
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 BEVMAR LN
Mailing Address - Street 2:
Mailing Address - City:ALAMO
Mailing Address - State:CA
Mailing Address - Zip Code:94507-1401
Mailing Address - Country:US
Mailing Address - Phone:925-336-6413
Mailing Address - Fax:
Practice Address - Street 1:30 BEVMAR LN
Practice Address - Street 2:
Practice Address - City:ALAMO
Practice Address - State:CA
Practice Address - Zip Code:94507-1401
Practice Address - Country:US
Practice Address - Phone:925-336-6413
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-24
Last Update Date:2025-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program