Provider Demographics
NPI:1801921119
Name:GUY, TARA LYNN (PA-C)
Entity type:Individual
Prefix:MRS
First Name:TARA
Middle Name:LYNN
Last Name:GUY
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 1:3676 PARKER BLVD
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81008-2212
Mailing Address - Country:US
Mailing Address - Phone:719-553-2201
Mailing Address - Fax:719-553-2224
Practice Address - Street 1:3676 PARKER BLVD
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81008-2212
Practice Address - Country:US
Practice Address - Phone:719-553-2201
Practice Address - Fax:719-553-2224
Is Sole Proprietor?:No
Enumeration Date:2007-02-23
Last Update Date:2015-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA1156363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO40725022Medicaid
804036Medicare ID - Type Unspecified
S98570Medicare UPIN