Healthcare Provider Details

I. General information

NPI: 1700262763
Provider Name (Legal Business Name): TARA GONZALES FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2015
Last Update Date: 07/19/2023
Certification Date: 07/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1861 E PARKS HWY
WASILLA AK
99654-7350
US

IV. Provider business mailing address

1861 E PARKS HWY
WASILLA AK
99654-7350
US

V. Phone/Fax

Practice location:
  • Phone: 888-227-3312
  • Fax:
Mailing address:
  • Phone: 888-227-3312
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP8007
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number206920
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: