Provider Demographics
NPI:1730798950
Name:WALKER, TARA T (PA)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:T
Last Name:WALKER
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:PO BOX 23666
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39225-3666
Mailing Address - Country:US
Mailing Address - Phone:601-200-4141
Mailing Address - Fax:601-200-4150
Practice Address - Street 1:106 HIGHLAND WAY STE 200
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:MS
Practice Address - Zip Code:39110-6933
Practice Address - Country:US
Practice Address - Phone:601-200-4141
Practice Address - Fax:601-200-4150
Is Sole Proprietor?:No
Enumeration Date:2020-07-23
Last Update Date:2021-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPA00514363AM0700X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS06934765Medicaid
MSPA00514OtherMS LICENSE
MS1K0604OtherMEDICARE ST DOM