1760981997 NPI number — MRS. TARA L GORDON APRN, FNP-BC

Table of content: MRS. TARA L GORDON APRN, FNP-BC (NPI 1760981997)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760981997 NPI number — MRS. TARA L GORDON APRN, FNP-BC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GORDON
Provider First Name:
TARA
Provider Middle Name:
L
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
APRN, FNP-BC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CARROLL
Provider Other First Name:
TARA
Provider Other Middle Name:
L
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
RN
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1760981997
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/02/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12403 ALTAMIRA ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AUSTIN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78748-4038
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
419-460-2476
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12403 ALTAMIRA ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AUSTIN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78748-4038
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
419-460-2476
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/02/2018

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  F12170077 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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