Basic Information
| Provider Information | |||||||||
| NPI: | 1891966743 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GIBLIN | ||||||||
| FirstName: | TARA | ||||||||
| MiddleName: | BRIDGET | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 40 SUNSHINE COTTAGE RD. | ||||||||
| Address2: | SKYLINE BUILDING, IN - J08 | ||||||||
| City: | VALHALLA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 10595 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9145942179 | ||||||||
| FaxNumber: | 9145942143 | ||||||||
| Practice Location | |||||||||
| Address1: | 19 BRADHURST AVENUE | ||||||||
| Address2: | SUITE 800S | ||||||||
| City: | HAWTHORNE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 10532 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9144937997 | ||||||||
| FaxNumber: | 9145942143 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/19/2008 | ||||||||
| LastUpdateDate: | 03/29/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 3181949 | NY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LP0200X | 381949 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics | 163W00000X | 576025-1 | NY | N | Nursing Service Providers | Registered Nurse |
ID Information
| ID | Type | State | Issuer | Description | 02969079 | 05 | NY | MEDICAID |