Provider Demographics
NPI:1558894329
Name:BOLKA, TARA WULFF (FNP-C)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:WULFF
Last Name:BOLKA
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:
Other - Last Name:PALMER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 3290
Mailing Address - Street 2:
Mailing Address - City:LA GRANDE
Mailing Address - State:OR
Mailing Address - Zip Code:97850-7290
Mailing Address - Country:US
Mailing Address - Phone:541-663-7313
Mailing Address - Fax:541-975-5120
Practice Address - Street 1:506 4TH ST
Practice Address - Street 2:
Practice Address - City:LA GRANDE
Practice Address - State:OR
Practice Address - Zip Code:97850-1906
Practice Address - Country:US
Practice Address - Phone:541-663-3138
Practice Address - Fax:541-975-5120
Is Sole Proprietor?:No
Enumeration Date:2017-04-07
Last Update Date:2024-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-089967363LF0000X
LA203981363LF0000X
OR201910351NP-PP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500773203Medicaid