Provider Demographics
NPI:1134650211
Name:BRENNER, TARA FAYE (MD)
Entity Type:Individual
Prefix:DR
First Name:TARA
Middle Name:FAYE
Last Name:BRENNER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 603949
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-3949
Mailing Address - Country:US
Mailing Address - Phone:919-350-0554
Mailing Address - Fax:
Practice Address - Street 1:3024 NEW BERN AVE FL 2
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27610-1247
Practice Address - Country:US
Practice Address - Phone:919-350-0554
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-21
Last Update Date:2022-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2021-00429207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1134650211Medicaid