Provider Demographics
NPI:1972488435
Name:KELLER, TARA RENEE
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:RENEE
Last Name:KELLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:356 N HAAS ST
Mailing Address - Street 2:
Mailing Address - City:FRANKENMUTH
Mailing Address - State:MI
Mailing Address - Zip Code:48734-1106
Mailing Address - Country:US
Mailing Address - Phone:989-293-4806
Mailing Address - Fax:
Practice Address - Street 1:356 N HAAS ST
Practice Address - Street 2:
Practice Address - City:FRANKENMUTH
Practice Address - State:MI
Practice Address - Zip Code:48734-1106
Practice Address - Country:US
Practice Address - Phone:989-293-4806
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-06
Last Update Date:2025-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant