Provider Demographics
NPI:1962787416
Name:BURGON, TARA I (CRNP)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:I
Last Name:BURGON
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3421 CONCORD RD
Mailing Address - Street 2:
Mailing Address - City:YORK
Mailing Address - State:PA
Mailing Address - Zip Code:17402-9001
Mailing Address - Country:US
Mailing Address - Phone:717-851-1700
Mailing Address - Fax:717-851-1710
Practice Address - Street 1:3065 WINDSOR RD
Practice Address - Street 2:
Practice Address - City:RED LION
Practice Address - State:PA
Practice Address - Zip Code:17356-8533
Practice Address - Country:US
Practice Address - Phone:717-851-1700
Practice Address - Fax:717-851-1710
Is Sole Proprietor?:No
Enumeration Date:2011-10-17
Last Update Date:2015-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP0011638363L00000X
PASP011638363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA230646FLTMedicare PIN