Provider Demographics
NPI:1134106263
Name:CHRISTENSEN-TOURTILLOTT, TARA R (PA-C)
Entity type:Individual
Prefix:MS
First Name:TARA
Middle Name:R
Last Name:CHRISTENSEN-TOURTILLOTT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:TARA
Other - Middle Name:R
Other - Last Name:CHRISTENSEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:3003 W GOOD HOPE RD
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53209-2042
Mailing Address - Country:US
Mailing Address - Phone:414-352-3100
Mailing Address - Fax:
Practice Address - Street 1:1575 N RIVERCENTER DR
Practice Address - Street 2:SUITE 160
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53212-3978
Practice Address - Country:US
Practice Address - Phone:414-274-7220
Practice Address - Fax:414-274-7227
Is Sole Proprietor?:No
Enumeration Date:2005-12-29
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1152-023363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42982700Medicaid
WIP00682030OtherRR MEDICARE
WIP00682030OtherRR MEDICARE
WI01994-0372Medicare PIN
WI46236-0373Medicare PIN