MEDICARE: DR. NADEGE TACHA GUNN M.D.

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	207RG0100X	Gastroenterology Physician	29135	SC
2	207RG0100X	Gastroenterology Physician	0101258366	VA
3	207RG0100X	Gastroenterology Physician	074062	GA
4	207RG0100X	Gastroenterology Physician	R4710	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	C06778	OTHER	VA	GROUP PTAN

General Provider Information

NPI Number	:	1902822281
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. NADEGE TACHA GUNN M.D.

Provider Business Mailing Address
First Line	:	6600 FISH POND RD STE 103
Second Line	:
City	:	WACO
State	:	TX
Zip	:	76710-2582
Country	:	US
Telephone Number	:	254-294-4780
Fax Number	:	254-294-4780

Provider Business Practice Location Address
First Line	:	6600 FISH POND RD STE 103
Second Line	:
City	:	WACO
State	:	TX
Zip	:	76710-2582
Country	:	US
Telephone Number	:	254-294-4780
Fax Number	:	254-294-4781

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

Provider Enumeration Date	:	07/13/2006
Last Update Date	:	08/01/2023

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