Basic Information
| Provider Information | |||||||||
| NPI: | 1124016118 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PELLETIER | ||||||||
| FirstName: | TARA | ||||||||
| MiddleName: | KAY | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 FODEN ROAD WEST | ||||||||
| Address2: | SUITE 203 | ||||||||
| City: | SOUTH PORTLAND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 04106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078280361 | ||||||||
| FaxNumber: | 2078741483 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 FODEN ROAD EAST | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | SOUTH PORTLAND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 04106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078741489 | ||||||||
| FaxNumber: | 2075238590 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2005 | ||||||||
| LastUpdateDate: | 02/22/2011 | ||||||||
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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 | 207Q00000X | 224963 | MA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 1957 | ME | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.