Provider Demographics
NPI:1861958720
Name:TEDFORD, TARA (NP)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:TEDFORD
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:
Other - Last Name:BOMBARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:PO BOX 2868
Mailing Address - Street 2:
Mailing Address - City:PLATTSBURGH
Mailing Address - State:NY
Mailing Address - Zip Code:12901-0259
Mailing Address - Country:US
Mailing Address - Phone:518-570-5794
Mailing Address - Fax:
Practice Address - Street 1:75 BEEKMAN ST
Practice Address - Street 2:
Practice Address - City:PLATTSBURGH
Practice Address - State:NY
Practice Address - Zip Code:12901-1438
Practice Address - Country:US
Practice Address - Phone:518-562-7377
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-15
Last Update Date:2022-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY344072363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily