Healthcare Provider Details

I. General information

NPI: 1396269312
Provider Name (Legal Business Name): TARA MARIE DISALLE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TARA MARIE O'TOOLE PA-C

II. Dates (important events)

Enumeration Date: 08/01/2017
Last Update Date: 04/12/2021
Certification Date: 04/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1691 W HORIZON RIDGE PKWY SUITE 100
HENDERSON NV
89012-3520
US

IV. Provider business mailing address

1691 W HORIZON RIDGE PKWY SUITE 100
HENDERSON NV
89012-3520
US

V. Phone/Fax

Practice location:
  • Phone: 702-804-1212
  • Fax: 702-804-1222
Mailing address:
  • Phone: 702-804-1212
  • Fax: 702-804-1222

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50.005132RX
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2405
License Number StateNV
# 3
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number50.005132RX
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: