MEDICARE: TARA JO TROUT 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
1	363A00000X	Physician Assistant	MA052621	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MA052621	OTHER	PA	PHYSICIAN ASSISTANT LICEN

General Provider Information

NPI Number	:	1801803432
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TARA JO TROUT PA-C

Provider Business Mailing Address
First Line	:	1701 CORNWALL RD
Second Line	:	SUITE 101
City	:	LEBANON
State	:	PA
Zip	:	17042-7480
Country	:	US
Telephone Number	:	717-675-1788
Fax Number	:	717-675-1800

Provider Business Practice Location Address
First Line	:	1701 CORNWALL RD
Second Line	:	SUITE 101
City	:	LEBANON
State	:	PA
Zip	:	17042-7480
Country	:	US
Telephone Number	:	717-675-1788
Fax Number	:	717-675-1800

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/03/2006
Last Update Date	:	08/31/2016

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Directions to “ TARA JO TROUT PA-C” Practice Location

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