Provider Demographics
NPI:1417943903
Name:TADDA, BERNARD P (FNP)
Entity Type:Individual
Prefix:
First Name:BERNARD
Middle Name:P
Last Name:TADDA
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 W RIVER DR
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52801-1014
Mailing Address - Country:US
Mailing Address - Phone:563-336-3000
Mailing Address - Fax:563-336-3125
Practice Address - Street 1:500 W RIVER DR
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52801-1014
Practice Address - Country:US
Practice Address - Phone:563-336-3000
Practice Address - Fax:563-336-3125
Is Sole Proprietor?:No
Enumeration Date:2005-09-21
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA080476363LF0000X
IL209002893363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA5201162OtherCONTROLLED SUBSTANCE#
IA421060724OtherBILLING TAX ID# FOR CHC
IAIA0133OtherJOHN DEERE EDI#
079606OtherHEALTH ALLIANCE
IA02253OtherIA BCBS SEEN IN DAVENPORT
IA42106072433OtherJOHN DEERE HEALTH
S55307OtherUPIN
S55307OtherUPIN
IA5201162OtherCONTROLLED SUBSTANCE#
IA42106072433OtherJOHN DEERE HEALTH
IA45158Medicare ID - Type UnspecifiedIA MEDICARE PART B