Healthcare Provider Details

I. General information

NPI: 1528244894
Provider Name (Legal Business Name): TARA POMPONIO PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/16/2008
Last Update Date: 12/27/2024
Certification Date: 12/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 MEDICAL PKWY SUITE 304
ANNAPOLIS MD
21401-3742
US

IV. Provider business mailing address

2000 MEDICAL PKWY STE 409
ANNAPOLIS MD
21401-3746
US

V. Phone/Fax

Practice location:
  • Phone: 410-573-9530
  • Fax:
Mailing address:
  • Phone: 667-204-7212
  • Fax: 443-481-4151

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberCO4459
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA18732
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: