Healthcare Provider Details

I. General information

NPI: 1730598046
Provider Name (Legal Business Name): TARA GATLIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2014
Last Update Date: 08/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

USS BARRY DDG 52
FPO AE
09565-1270
US

IV. Provider business mailing address

SURFACE WARFARE MEDICAL INSTITUTE 34101 FARENHOLT AVENUE, BUILDING 14
SAN DIEGO CA
92134-5291
US

V. Phone/Fax

Practice location:
  • Phone: 757-444-1152
  • Fax:
Mailing address:
  • Phone: 619-532-7968
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: