Provider Demographics
NPI:1083696868
Name:BUSH, TARA DENISE (NP)
Entity Type:Individual
Prefix:MRS
First Name:TARA
Middle Name:DENISE
Last Name:BUSH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MS
Other - First Name:TARA
Other - Middle Name:DENISE
Other - Last Name:NORMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:707 LASSITER ST
Mailing Address - Street 2:
Mailing Address - City:SMITHFIELD
Mailing Address - State:NC
Mailing Address - Zip Code:27577-4613
Mailing Address - Country:US
Mailing Address - Phone:919-209-9856
Mailing Address - Fax:919-209-9859
Practice Address - Street 1:707 LASSITER ST
Practice Address - Street 2:
Practice Address - City:SMITHFIELD
Practice Address - State:NC
Practice Address - Zip Code:27577-4613
Practice Address - Country:US
Practice Address - Phone:919-209-9856
Practice Address - Fax:919-209-9859
Is Sole Proprietor?:No
Enumeration Date:2005-11-16
Last Update Date:2008-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9600390363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCP10968Medicare UPIN