Provider Demographics
NPI:1548866494
Name:ARDITO, TARA C (PA)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:C
Last Name:ARDITO
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 1:180 PARKWOOD DR
Mailing Address - Street 2:
Mailing Address - City:ELKIN
Mailing Address - State:NC
Mailing Address - Zip Code:28621-2430
Mailing Address - Country:US
Mailing Address - Phone:336-527-7000
Mailing Address - Fax:
Practice Address - Street 1:911 E ATKINS ST
Practice Address - Street 2:
Practice Address - City:DOBSON
Practice Address - State:NC
Practice Address - Zip Code:27017-8708
Practice Address - Country:US
Practice Address - Phone:336-374-1113
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-07
Last Update Date:2024-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA390200000X
NC0010-12836207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program