Active NPI
Tara Doherty
- Athletic Trainer
- Woodbury, MN
National Provider Identifier
1962195305
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Athletic Trainer
- License
- 3784
- Practice address
- 2090 Woodwinds Dr
Woodbury, MN 55125-2522 - Phone
- (651) 968-5201
- NPI assigned
- May 31, 2023
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Athletic Trainer | 2255A2300X | 3784 | MN | Primary |
Addresses
Primary practice location
2090 Woodwinds Dr
Woodbury, MN 55125-2522
Mailing address
1845 Onacrest CT
Maplewood, MN 55117-2329
Phone (651) 214-3603
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 3784 | MN | MD | Optometrist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1685491200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1718496000000",
"number": "1962195305",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1845 ONACREST CT",
"city": "MAPLEWOOD",
"state": "MN",
"postal_code": "551172329",
"telephone_number": "651-214-3603"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "2090 WOODWINDS DR",
"city": "WOODBURY",
"state": "MN",
"postal_code": "551252522",
"telephone_number": "651-968-5201"
}
],
"practiceLocations": [],
"basic": {
"last_name": "DOHERTY",
"first_name": "TARA",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2023-05-31",
"last_updated": "2024-06-16",
"certification_date": "2024-06-16",
"status": "A"
},
"taxonomies": [
{
"code": "2255A2300X",
"taxonomy_group": "",
"desc": "Specialist/Technologist, Athletic Trainer",
"state": "MN",
"license": "3784",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Woodbury, MN
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 16, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.