Provider Demographics
NPI:1588704118
Name:KISHPAUGH, TARA ANNE (LAT, AT,C)
Entity type:Individual
Prefix:MRS
First Name:TARA
Middle Name:ANNE
Last Name:KISHPAUGH
Suffix:
Gender:F
Credentials:LAT, AT,C
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:ANNE
Other - Last Name:PRICE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LAT, AT,C
Mailing Address - Street 1:1229 FLEETWOOD LN
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-4541
Mailing Address - Country:US
Mailing Address - Phone:208-866-9495
Mailing Address - Fax:
Practice Address - Street 1:574 PARK LN
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-4512
Practice Address - Country:US
Practice Address - Phone:208-939-2189
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDAT-2802255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer