Healthcare Provider Details

I. General information

NPI: 1013597871
Provider Name (Legal Business Name): TARA MORDER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2021
Last Update Date: 10/25/2021
Certification Date: 10/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 6TH AVE S
ST PETERSBURG FL
33701-4634
US

IV. Provider business mailing address

1 MEDICAL CENTER DR
MORGANTOWN WV
26506-1200
US

V. Phone/Fax

Practice location:
  • Phone: 727-767-4313
  • Fax: 727-767-4391
Mailing address:
  • Phone: 800-988-2273
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LN0000X
TaxonomyNeonatal Nurse Practitioner
License Number108858
License Number StateWV
# 2
Primary TaxonomyY
Taxonomy Code363LN0000X
TaxonomyNeonatal Nurse Practitioner
License NumberAPRN11013767
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: