Provider Demographics
NPI:1124213418
Name:VANHISE, TARA HUNGSPRUKE (DO)
Entity Type:Individual
Prefix:DR
First Name:TARA
Middle Name:HUNGSPRUKE
Last Name:VANHISE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:TARA
Other - Middle Name:KIMBERLY
Other - Last Name:HUNGSPRUKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:1230 PARKWAY AVE
Mailing Address - Street 2:SUITE 203
Mailing Address - City:EWING
Mailing Address - State:NJ
Mailing Address - Zip Code:08628-3018
Mailing Address - Country:US
Mailing Address - Phone:609-883-5454
Mailing Address - Fax:609-883-2656
Practice Address - Street 1:1230 PARKWAY AVE
Practice Address - Street 2:SUITE 203
Practice Address - City:EWING
Practice Address - State:NJ
Practice Address - Zip Code:08628-3018
Practice Address - Country:US
Practice Address - Phone:609-883-5454
Practice Address - Fax:609-883-2565
Is Sole Proprietor?:No
Enumeration Date:2007-09-10
Last Update Date:2021-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB08328800207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0181161Medicaid
NJ0181161Medicaid