Basic Information
| Provider Information | |||||||||
| NPI: | 1760660070 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WEATHERS | ||||||||
| FirstName: | TARA | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | NP | ||||||||
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| OtherLastName: | WEATHERS | ||||||||
| OtherFirstName: | TARA | ||||||||
| OtherMiddleName: | A | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 785377 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191785377 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2036886743 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 593 EDDY ST | ||||||||
| Address2: | CLAVERICK 2 | ||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029034923 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4014445175 | ||||||||
| FaxNumber: | 4014448874 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2008 | ||||||||
| LastUpdateDate: | 02/11/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 8686 | CT | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | APRN00110 | RI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | NPP37450 | RI | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 0070601881 | 01 | RI | RI MEDICARE | OTHER | 939025129 | 01 | RI | RI MEDICARE UEMF GROUP PROVIDER | OTHER | TW69699 | 05 | RI | MEDICAID | 06/10/2008 | 01 | RI | BCBS | OTHER | 718882 | 05 | MA | MEDICAID | 05/08/2008 | 01 | RI | NHPRI | OTHER |