Healthcare Provider Details

I. General information

NPI: 1598835811
Provider Name (Legal Business Name): TARA LYNN SALLEY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2006
Last Update Date: 02/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 CHEYENNE AVE
LAME DEER MT
59043-0070
US

IV. Provider business mailing address

PO BOX 70
LAME DEER MT
59043-0070
US

V. Phone/Fax

Practice location:
  • Phone: 406-477-4484
  • Fax: 406-477-3153
Mailing address:
  • Phone: 406-477-4484
  • Fax: 406-477-3153

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number480
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: