MEDICARE: TARA GANN NP

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	363LP2300X	Primary Care Nurse Practitioner	AP7879	AZ

General Provider Information

NPI Number	:	1043691520
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TARA GANN NP

Provider Business Mailing Address
First Line	:	1503 W COUNTRY CLUB DR
Second Line	:
City	:	PAYSON
State	:	AZ
Zip	:	85541-4611
Country	:	US
Telephone Number	:	928-951-2189
Fax Number	:

Provider Business Practice Location Address
First Line	:	405 W MAIN ST STE B
Second Line	:
City	:	PAYSON
State	:	AZ
Zip	:	85541-5345
Country	:	US
Telephone Number	:	928-472-6000
Fax Number	:	844-752-8246

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

Provider Enumeration Date	:	06/10/2015
Last Update Date	:	09/13/2019

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