Healthcare Provider Details

I. General information

NPI: 1609763283
Provider Name (Legal Business Name): TARA RENEE O'DONNELL PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2025
Last Update Date: 06/18/2025
Certification Date: 06/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 PROSPECT AVE STE 903
HACKENSACK NJ
07601-1999
US

IV. Provider business mailing address

PO BOX 1093
ISLAND HEIGHTS NJ
08732-1093
US

V. Phone/Fax

Practice location:
  • Phone: 551-228-2208
  • Fax:
Mailing address:
  • Phone: 732-703-5915
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: