Provider Demographics
NPI:1710123336
Name:RAINEY, TARA MARIE (PA-C)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:MARIE
Last Name:RAINEY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:494 IVY RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:DEEP GAP
Mailing Address - State:NC
Mailing Address - Zip Code:28618-9055
Mailing Address - Country:US
Mailing Address - Phone:512-948-1544
Mailing Address - Fax:
Practice Address - Street 1:211 MILTON BROWN HEIRS RD
Practice Address - Street 2:
Practice Address - City:BOONE
Practice Address - State:NC
Practice Address - Zip Code:28607-8708
Practice Address - Country:US
Practice Address - Phone:512-948-1544
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-02
Last Update Date:2024-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA04961363A00000X
NC0010-14057363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8L8656Medicare PIN
P00754597Medicare PIN