Healthcare Provider Details

I. General information

NPI: 1376432161
Provider Name (Legal Business Name): TARA SHORES PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2025
Last Update Date: 09/16/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4755 OGLETOWN STANTON RD
NEWARK DE
19718-2200
US

IV. Provider business mailing address

24 ADDISON LN
MALVERN PA
19355-1943
US

V. Phone/Fax

Practice location:
  • Phone: 302-733-1000
  • Fax:
Mailing address:
  • Phone: 484-798-3604
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateDE
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: