Provider Demographics
NPI:1043691520
Name:GANN, TARA (NP)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:GANN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:
Other - Last Name:DALHAUG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1503 W COUNTRY CLUB DR
Mailing Address - Street 2:
Mailing Address - City:PAYSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85541-4611
Mailing Address - Country:US
Mailing Address - Phone:928-951-2189
Mailing Address - Fax:
Practice Address - Street 1:405 W MAIN ST STE B
Practice Address - Street 2:
Practice Address - City:PAYSON
Practice Address - State:AZ
Practice Address - Zip Code:85541-5345
Practice Address - Country:US
Practice Address - Phone:928-472-6000
Practice Address - Fax:844-752-8246
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-10
Last Update Date:2019-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP7879363LP2300X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Single Specialty