Healthcare Provider Details

I. General information

NPI: 1922350255
Provider Name (Legal Business Name): TARA MARCHIDO NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2012
Last Update Date: 10/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3050 REGENT BLVD SUITE100
IRVING TX
75063-3196
US

IV. Provider business mailing address

7474 ELM GROVE AVE
EASTVALE CA
92880-9066
US

V. Phone/Fax

Practice location:
  • Phone: 214-689-3600
  • Fax: 214-689-3644
Mailing address:
  • Phone: 951-279-9175
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number14202
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number14202
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: