Basic Information
Provider Information | |||||||||
NPI: | 1558868067 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DOROSH | ||||||||
FirstName: | TARA | ||||||||
MiddleName: | ASHLEY | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | WRIGHT | ||||||||
OtherFirstName: | TARA | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1610 W CANFIELD AVE | ||||||||
Address2: |   | ||||||||
City: | COEUR D ALENE | ||||||||
State: | ID | ||||||||
PostalCode: | 838158457 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2084205606 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 750 N SYRINGA ST STE 205 | ||||||||
Address2: |   | ||||||||
City: | POST FALLS | ||||||||
State: | ID | ||||||||
PostalCode: | 83854 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2082620945 | ||||||||
FaxNumber: | 2084150150 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/11/2018 | ||||||||
LastUpdateDate: | 07/01/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/01/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA-1607 | ID | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
No ID Information.