Provider Demographics
NPI:1609063825
Name:DEITER-ENRIGHT, TARRA LOUISA (DO)
Entity type:Individual
Prefix:DR
First Name:TARRA
Middle Name:LOUISA
Last Name:DEITER-ENRIGHT
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:424 YELLOWSTONE AVE STE 230
Mailing Address - Street 2:
Mailing Address - City:CODY
Mailing Address - State:WY
Mailing Address - Zip Code:82414-9310
Mailing Address - Country:US
Mailing Address - Phone:307-578-2975
Mailing Address - Fax:307-578-2979
Practice Address - Street 1:424 YELLOWSTONE AVE STE 230
Practice Address - Street 2:
Practice Address - City:CODY
Practice Address - State:WY
Practice Address - Zip Code:82414-9310
Practice Address - Country:US
Practice Address - Phone:307-578-2975
Practice Address - Fax:307-578-2979
Is Sole Proprietor?:No
Enumeration Date:2007-10-02
Last Update Date:2024-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY14504A207R00000X
CO48647207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO50734555Medicaid
CO271559YK1COtherMEDICARE PTAN FOR SOUND FOR CENTURA
WY215506100Medicaid