Provider Demographics
NPI:1972523850
Name:EDICK, TARA J (PA)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:J
Last Name:EDICK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:360 PEAK ONE DR
Mailing Address - Street 2:STE 260
Mailing Address - City:FRISCO
Mailing Address - State:CO
Mailing Address - Zip Code:80443
Mailing Address - Country:US
Mailing Address - Phone:970-668-5584
Mailing Address - Fax:970-262-2196
Practice Address - Street 1:777 BANNOCK ST
Practice Address - Street 2:MC 7782
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80204-4507
Practice Address - Country:US
Practice Address - Phone:303-436-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2023-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1653363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant