Provider Demographics
NPI:1528052750
Name:NELSON, TARA MICHELE (PA)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:MICHELE
Last Name:NELSON
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 1:331 SIJEN AVE
Mailing Address - Street 2:
Mailing Address - City:WHITEMAN AFB
Mailing Address - State:MO
Mailing Address - Zip Code:65305-1269
Mailing Address - Country:US
Mailing Address - Phone:660-687-2188
Mailing Address - Fax:660-687-4414
Practice Address - Street 1:331 SIJEN AVE
Practice Address - Street 2:
Practice Address - City:WHITEMAN AIR FORCE BASE
Practice Address - State:MO
Practice Address - Zip Code:65305-1269
Practice Address - Country:US
Practice Address - Phone:660-687-2188
Practice Address - Fax:660-687-2106
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-02
Last Update Date:2024-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS15-00527363A00000X
MOPYA113653363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant