MEDICARE: MRS. BRENDA TATUM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171W00000X	Contractor	811752	AZ

General Provider Information

NPI Number	:	1417117177
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. BRENDA TATUM

Provider Business Mailing Address
First Line	:	994 S HARRISON ROAD
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85748
Country	:	US
Telephone Number	:	520-721-1887
Fax Number	:

Provider Business Practice Location Address
First Line	:	17255 S GOLDEN SUNRISE PL
Second Line	:
City	:	CORONA DE TUCSON
State	:	AZ
Zip	:	85641-2720
Country	:	US
Telephone Number	:	520-777-4551
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/16/2008
Last Update Date	:	06/16/2008

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