MEDICARE: TARA GANN DNP

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	:	1578072872
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TARA GANN DNP

Provider Business Mailing 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

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	:	PRESIDENT
Name	:	TARA GANN
Credential	:	NP
Telephone Number	:	928-951-2189

Provider Enumeration Date	:	09/29/2017
Last Update Date	:	01/13/2022

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