Provider Demographics
NPI:1760636302
Name:REISS, TARA ANDREA (PA-C)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:ANDREA
Last Name:REISS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:ANDREA
Other - Last Name:BRENNAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3115D BRUSHY CREEK RD
Mailing Address - Street 2:
Mailing Address - City:GREER
Mailing Address - State:SC
Mailing Address - Zip Code:29650-0903
Mailing Address - Country:US
Mailing Address - Phone:864-877-4221
Mailing Address - Fax:864-877-1711
Practice Address - Street 1:3115D BRUSHY CREEK RD
Practice Address - Street 2:
Practice Address - City:GREER
Practice Address - State:SC
Practice Address - Zip Code:29650-0903
Practice Address - Country:US
Practice Address - Phone:864-877-4221
Practice Address - Fax:864-877-1711
Is Sole Proprietor?:No
Enumeration Date:2008-11-10
Last Update Date:2010-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1342363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical