Provider Demographics
NPI:1396269312
Name:DISALLE, TARA MARIE (PA-C)
Entity type:Individual
Prefix:MS
First Name:TARA
Middle Name:MARIE
Last Name:DISALLE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:MARIE
Other - Last Name:O'TOOLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1691 W HORIZON RIDGE PKWY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89012-3520
Mailing Address - Country:US
Mailing Address - Phone:702-804-1212
Mailing Address - Fax:702-804-1222
Practice Address - Street 1:1691 W HORIZON RIDGE PKWY
Practice Address - Street 2:SUITE 100
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89012-3520
Practice Address - Country:US
Practice Address - Phone:702-804-1212
Practice Address - Fax:702-804-1222
Is Sole Proprietor?:No
Enumeration Date:2017-08-01
Last Update Date:2021-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.005132RX207P00000X, 363A00000X
NVPA2405363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine