Provider Demographics
NPI:1205414307
Name:GILBERT, TARA J
Entity Type:Individual
Prefix:MRS
First Name:TARA
Middle Name:J
Last Name:GILBERT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 9TH ST S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-1830
Mailing Address - Country:US
Mailing Address - Phone:701-212-8626
Mailing Address - Fax:
Practice Address - Street 1:111 9TH ST S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-1831
Practice Address - Country:US
Practice Address - Phone:701-212-8626
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-30
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND251B00000XMedicaid
ND251S00000XMedicaid
ND347C00000XMedicaid