Provider Demographics
NPI:1003102187
Name:GOODMAN, TARA R (ARNP)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:R
Last Name:GOODMAN
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1219 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HAMBURG
Mailing Address - State:IA
Mailing Address - Zip Code:51640-1300
Mailing Address - Country:US
Mailing Address - Phone:712-382-2626
Mailing Address - Fax:712-382-1931
Practice Address - Street 1:1219 MAIN ST
Practice Address - Street 2:
Practice Address - City:HAMBURG
Practice Address - State:IA
Practice Address - Zip Code:51640-1300
Practice Address - Country:US
Practice Address - Phone:712-382-2626
Practice Address - Fax:712-382-1931
Is Sole Proprietor?:No
Enumeration Date:2011-06-27
Last Update Date:2011-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAC107297363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics