Healthcare Provider Details

I. General information

NPI: 1386886620
Provider Name (Legal Business Name): TARA M WILSON CFA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/01/2009
Last Update Date: 06/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13430 N MERIDIAN ST SUITE 275
CARMEL IN
46032-1405
US

IV. Provider business mailing address

13430 N MERIDIAN ST SUITE 275
CARMEL IN
46032-1405
US

V. Phone/Fax

Practice location:
  • Phone: 317-582-8810
  • Fax: 317-582-8863
Mailing address:
  • Phone: 317-582-8810
  • Fax: 317-582-8863

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number113533
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: