Basic Information
Provider Information | |||||||||
NPI: | 1609321074 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BOYLE | ||||||||
FirstName: | TARA | ||||||||
MiddleName: | L | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | PELLERITO | ||||||||
OtherFirstName: | TARA | ||||||||
OtherMiddleName: | L | ||||||||
OtherNamePrefix: | MRS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PA-C | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 11350 MCCORMICK RD | ||||||||
Address2: | EXECUTIVE PLAZA 1, SUITE 501 | ||||||||
City: | HUNT VALLEY | ||||||||
State: | MD | ||||||||
PostalCode: | 21031 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4103291071 | ||||||||
FaxNumber: | 4103291054 | ||||||||
Practice Location | |||||||||
Address1: | 8 SAXON AVE STE A | ||||||||
Address2: |   | ||||||||
City: | BAY SHORE | ||||||||
State: | NY | ||||||||
PostalCode: | 117067036 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6312061034 | ||||||||
FaxNumber: | 6312061046 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/16/2016 | ||||||||
LastUpdateDate: | 03/07/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/07/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 019992-1 | NY | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
No ID Information.