Provider Demographics
NPI:1235385279
Name:TAVARES, DEBORAH (FNP)
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:
Last Name:TAVARES
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1019 MILLSTONE CT
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:IN
Mailing Address - Zip Code:46131-3600
Mailing Address - Country:US
Mailing Address - Phone:317-502-7072
Mailing Address - Fax:
Practice Address - Street 1:9900 BREN RD E
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55343-9664
Practice Address - Country:US
Practice Address - Phone:317-502-7072
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-11
Last Update Date:2020-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0017139993363LF0000X
IN71001521A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN232230QQQQMedicare PIN