Provider Demographics
NPI:1316380439
Name:SONNANSTINE, TARA BAGEN (MD)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:BAGEN
Last Name:SONNANSTINE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:K
Other - Last Name:BAGEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:13020 N TELECOM PKWY
Mailing Address - Street 2:
Mailing Address - City:TEMPLE TERRACE
Mailing Address - State:FL
Mailing Address - Zip Code:33637-0925
Mailing Address - Country:US
Mailing Address - Phone:813-978-9700
Mailing Address - Fax:
Practice Address - Street 1:13020 N TELECOM PKWY
Practice Address - Street 2:
Practice Address - City:TEMPLE TERRACE
Practice Address - State:FL
Practice Address - Zip Code:33637-0925
Practice Address - Country:US
Practice Address - Phone:813-978-9700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-08
Last Update Date:2022-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXR2811207Q00000X
390200000X
FLME134360207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program