Healthcare Provider Details

I. General information

NPI: 1295710952
Provider Name (Legal Business Name): TARA D LOUKA PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/14/2005
Last Update Date: 02/03/2020
Certification Date: 02/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 7TH ST N
NAPLES FL
34102-5754
US

IV. Provider business mailing address

7101 JAHNKE ROAD SUITE 550
RICHMOND VA
23225
US

V. Phone/Fax

Practice location:
  • Phone: 239-624-4200
  • Fax: 239-624-4241
Mailing address:
  • Phone: 804-560-8880
  • Fax: 804-560-9577

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9111974
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: