Provider Demographics
NPI:1720436975
Name:HADLOCK, TARA GORMLEY-HARKINS
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:GORMLEY-HARKINS
Last Name:HADLOCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:887 CONGRESS ST STE 300
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04102-3103
Mailing Address - Country:US
Mailing Address - Phone:207-662-5555
Mailing Address - Fax:
Practice Address - Street 1:887 CONGRESS ST STE 400
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-3163
Practice Address - Country:US
Practice Address - Phone:207-662-5555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-28
Last Update Date:2023-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPA1927363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical