Provider Demographics
NPI:1972229391
Name:MARTIN, TARA (PTA)
Entity type:Individual
Prefix:MISS
First Name:TARA
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:855 LYDIA DR
Mailing Address - Street 2:
Mailing Address - City:WARSAW
Mailing Address - State:IN
Mailing Address - Zip Code:46582-1949
Mailing Address - Country:US
Mailing Address - Phone:574-253-2482
Mailing Address - Fax:
Practice Address - Street 1:3715 UNION CHAPEL RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-7400
Practice Address - Country:US
Practice Address - Phone:260-483-5590
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-17
Last Update Date:2022-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06005857A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant