Provider Demographics
NPI:1356527063
Name:LASSILA, TARA LYNN (PA)
Entity type:Individual
Prefix:MS
First Name:TARA
Middle Name:LYNN
Last Name:LASSILA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 CAMPUS DR
Mailing Address - Street 2:
Mailing Address - City:HANCOCK
Mailing Address - State:MI
Mailing Address - Zip Code:49930-1569
Mailing Address - Country:US
Mailing Address - Phone:906-483-1000
Mailing Address - Fax:906-483-1147
Practice Address - Street 1:500 CAMPUS DR
Practice Address - Street 2:
Practice Address - City:HANCOCK
Practice Address - State:MI
Practice Address - Zip Code:49930-1569
Practice Address - Country:US
Practice Address - Phone:906-483-1000
Practice Address - Fax:906-483-1147
Is Sole Proprietor?:No
Enumeration Date:2008-01-11
Last Update Date:2016-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TL955786133V00000X
MI5601007849363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0C16002OtherMEDICARE GROUP