Basic Information
| Provider Information | |||||||||
| NPI: | 1942772967 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | TARA | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6856 RIVERVIEW RD | ||||||||
| Address2: | |||||||||
| City: | RIVERTON | ||||||||
| State: | WY | ||||||||
| PostalCode: | 825019322 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3078573138 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1002 FOREST DR | ||||||||
| Address2: | |||||||||
| City: | RIVERTON | ||||||||
| State: | WY | ||||||||
| PostalCode: | 825012918 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3078569471 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/02/2019 | ||||||||
| LastUpdateDate: | 01/02/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | PTA-0454 | WY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.