Basic Information
| Provider Information | |||||||||
| NPI: | 1962908954 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HAJARAT | ||||||||
| FirstName: | TARA | ||||||||
| MiddleName: | JAWAD | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | M.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 406 KINGS POINT LANE | ||||||||
| Address2: | # 406 | ||||||||
| City: | MORGANTOWN | ||||||||
| State: | WV | ||||||||
| PostalCode: | 26508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7135025105 | ||||||||
| FaxNumber: | 7137983665 | ||||||||
| Practice Location | |||||||||
| Address1: | 64 MEDICAL CENTER DRIVE | ||||||||
| Address2: | 2305 HSCN, WVU DEPARTMENT OF PATHOLOGY | ||||||||
| City: | MORGANTOWN | ||||||||
| State: | WV | ||||||||
| PostalCode: | 26506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3042931621 | ||||||||
| FaxNumber: | 7137983665 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/30/2018 | ||||||||
| LastUpdateDate: | 02/18/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 12/07/2018 | ||||||||
| NPIReactivationDate: | 02/18/2020 | ||||||||
| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.