Basic Information
| Provider Information | |||||||||
| NPI: | 1821614991 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TRENHAILE | ||||||||
| FirstName: | TARA | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | PHYSICIAN ASSISTANT | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2147 | ||||||||
| Address2: | |||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339022147 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2393439646 | ||||||||
| FaxNumber: | 2393439681 | ||||||||
| Practice Location | |||||||||
| Address1: | 8960 COLONIAL CENTER DR STE 202 | ||||||||
| Address2: | |||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339057810 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2393439646 | ||||||||
| FaxNumber: | 2393439681 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2020 | ||||||||
| LastUpdateDate: | 01/05/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 0010-10292 | NC | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363A00000X | PA9115050 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 112702700 | 05 | FL | MEDICAID |