Basic Information
| Provider Information | |||||||||
| NPI: | 1043286933 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROA | ||||||||
| FirstName: | TARA | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2214 CANTERBURY DR | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | HAYS | ||||||||
| State: | KS | ||||||||
| PostalCode: | 676012375 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7856232312 | ||||||||
| FaxNumber: | 7856232323 | ||||||||
| Practice Location | |||||||||
| Address1: | 2214 CANTERBURY DR | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | HAYS | ||||||||
| State: | KS | ||||||||
| PostalCode: | 676012375 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7856232312 | ||||||||
| FaxNumber: | 7856232323 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 15-00907 | KS | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.