Provider Demographics
NPI:1588743348
Name:JARDIM, TASHA R (PA-C)
Entity type:Individual
Prefix:MS
First Name:TASHA
Middle Name:R
Last Name:JARDIM
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:TASHA
Other - Middle Name:
Other - Last Name:KOCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:100 N ACADEMY AVE
Mailing Address - Street 2:CREDENTIALS DEPT
Mailing Address - City:DANVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17822-4903
Mailing Address - Country:US
Mailing Address - Phone:570-271-6144
Mailing Address - Fax:
Practice Address - Street 1:100 N ACADEMY AVE
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:PA
Practice Address - Zip Code:17822-2150
Practice Address - Country:US
Practice Address - Phone:570-271-6367
Practice Address - Fax:570-271-7142
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2025-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA052632363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q73947Medicare UPIN