Provider Demographics
NPI:1982158085
Name:ORTIZ, TARA
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:ORTIZ
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 1:1000 BOULDERS PKWY
Mailing Address - Street 2:SUITE 102
Mailing Address - City:NORTH CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23225-5545
Mailing Address - Country:US
Mailing Address - Phone:804-320-4243
Mailing Address - Fax:804-622-0552
Practice Address - Street 1:1000 BOULDERS PKWY
Practice Address - Street 2:SUITE 102
Practice Address - City:NORTH CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23225-5545
Practice Address - Country:US
Practice Address - Phone:804-320-4243
Practice Address - Fax:804-622-0552
Is Sole Proprietor?:No
Enumeration Date:2016-08-08
Last Update Date:2022-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024173814363LA2100X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care