Provider Demographics
NPI:1427107531
Name:LEWIS, TARA MARIE (NP)
Entity type:Individual
Prefix:MRS
First Name:TARA
Middle Name:MARIE
Last Name:LEWIS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 WINDING WOOD CT
Mailing Address - Street 2:
Mailing Address - City:MOUNT SINAI
Mailing Address - State:NY
Mailing Address - Zip Code:11766-3319
Mailing Address - Country:US
Mailing Address - Phone:631-331-3652
Mailing Address - Fax:
Practice Address - Street 1:200 BELLE TERRE RD
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11777-1928
Practice Address - Country:US
Practice Address - Phone:631-474-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF381695363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics