Basic Information
| Provider Information | |||||||||
| NPI: | 1528244894 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | POMPONIO | ||||||||
| FirstName: | TARA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 12622 | ||||||||
| Address2: | |||||||||
| City: | BELFAST | ||||||||
| State: | ME | ||||||||
| PostalCode: | 049154017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4105739530 | ||||||||
| FaxNumber: | 4105739568 | ||||||||
| Practice Location | |||||||||
| Address1: | 2000 MEDICAL PKWY | ||||||||
| Address2: | SUITE 304 | ||||||||
| City: | ANNAPOLIS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 214013742 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4105739530 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/16/2008 | ||||||||
| LastUpdateDate: | 10/31/2017 | ||||||||
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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 | 363AM0700X | PA18732 | CA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363A00000X | CO4459 | MD | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 596754ZDWS | 01 | MD | MEDICARE | OTHER | 596754Y5Z | 01 | MD | MEDICARE | OTHER |