Provider Demographics
NPI:1033528500
Name:GOOSSEN, TARA L (CRNP)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:L
Last Name:GOOSSEN
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4815 LIBERTY AVE STE 158
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15224-2156
Mailing Address - Country:US
Mailing Address - Phone:412-578-1519
Mailing Address - Fax:412-605-6342
Practice Address - Street 1:4815 LIBERTY AVE STE 158
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15224-2156
Practice Address - Country:US
Practice Address - Phone:412-578-1519
Practice Address - Fax:412-605-6342
Is Sole Proprietor?:No
Enumeration Date:2014-08-08
Last Update Date:2020-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP014217363L00000X
FLARNP9415101363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL016655300Medicaid
PA1030105073Medicaid
PA405137OtherMEDICARE
FLDX8IIOtherBLUE CROSS BLUE SHIELD
FLIM322ZMedicare PIN