Provider Demographics
NPI:1326417171
Name:DESHAZO, TAMARA (APRN, FNP-C)
Entity Type:Individual
Prefix:
First Name:TAMARA
Middle Name:
Last Name:DESHAZO
Suffix:
Gender:F
Credentials:APRN, FNP-C
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 211699
Mailing Address - Street 2:
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55121-3699
Mailing Address - Country:US
Mailing Address - Phone:866-849-0692
Mailing Address - Fax:888-973-8821
Practice Address - Street 1:20405 STATE HIGHWAY 249 STE 325
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77070-2893
Practice Address - Country:US
Practice Address - Phone:866-849-0692
Practice Address - Fax:888-973-8821
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-23
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.029032363L00000X
OR10011924363L00000X
FLAPRN11024231363L00000X
AZ298265363L00000X
COC-APN.0100877-C-NP363L00000X
HIAPRN-4482363L00000X
TXAP130591363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner