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NPI Code Detail

MEDICARE: MRS. TARA LYNN KAVANAUGH PA-C

MEDICARE: MRS. TARA LYNN KAVANAUGH PA-C
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1363A00000XPhysician AssistantPA1111NV
2363A00000XPhysician AssistantC0003211MD
3363AM0700XMedical Physician Assistant10088016-1206UT

General Provider Information

NPI Number : 1306968482
Entity Type Code : Individual
Provider Name (Legal Business Name) : MRS. TARA LYNN KAVANAUGH PA-C
Provider Business Mailing Address
First Line : PO BOX 3299
Second Line :
City : CARSON CITY
State : NV
Zip : 89702-3299
Country : US
Telephone Number : 775-222-0042
Fax Number : 775-222-0056
Provider Business Practice Location Address
First Line : 5505 S 900 E STE 240
Second Line :
City : MURRAY
State : UT
Zip : 84117-7210
Country : US
Telephone Number : 801-783-5011
Fax Number : 801-746-3734
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 04/06/2007
Last Update Date : 07/21/2022

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