Provider Demographics
NPI:1164987715
Name:BUNCH, TARA CHRISTINE (FNP-C)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:CHRISTINE
Last Name:BUNCH
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:
Other - Last Name:SCOTT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 631310
Mailing Address - Street 2:
Mailing Address - City:NACOGDOCHES
Mailing Address - State:TX
Mailing Address - Zip Code:75963-1310
Mailing Address - Country:US
Mailing Address - Phone:936-585-4646
Mailing Address - Fax:936-585-4645
Practice Address - Street 1:1209 N MOUND ST
Practice Address - Street 2:
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75961-4028
Practice Address - Country:US
Practice Address - Phone:936-585-4646
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-07
Last Update Date:2019-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP140471363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner