Healthcare Provider Details

I. General information

NPI: 1164455689
Provider Name (Legal Business Name): TARA N CLEMENS PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2006
Last Update Date: 11/08/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5995 IRIS PARKWAY BOX 189
FREDERICK CO
80530
US

IV. Provider business mailing address

203 S ROLLIE AVE
FORT LUPTON CO
80621-1508
US

V. Phone/Fax

Practice location:
  • Phone: 303-833-2050
  • Fax: 303-833-9183
Mailing address:
  • Phone: 303-286-4560
  • Fax: 303-286-4589

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA.0002098
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: