Provider Demographics
NPI:1972987626
Name:ATWATER, TARA (RN, BSN)
Entity type:Individual
Prefix:MS
First Name:TARA
Middle Name:
Last Name:ATWATER
Suffix:
Gender:F
Credentials:RN, BSN
Other - Prefix:MRS
Other - First Name:TARA
Other - Middle Name:
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RN, BSN
Mailing Address - Street 1:6 BALMORAL WAY
Mailing Address - Street 2:
Mailing Address - City:HOMER
Mailing Address - State:NY
Mailing Address - Zip Code:13077-9417
Mailing Address - Country:US
Mailing Address - Phone:607-423-6980
Mailing Address - Fax:
Practice Address - Street 1:6101 E MOLLOY RD
Practice Address - Street 2:
Practice Address - City:EAST SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13057-1175
Practice Address - Country:US
Practice Address - Phone:315-432-5636
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-13
Last Update Date:2015-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY629898-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse