Provider Demographics
NPI:1629302567
Name:SUNDEM, TARA SUE (NNP)
Entity Type:Individual
Prefix:MRS
First Name:TARA
Middle Name:SUE
Last Name:SUNDEM
Suffix:
Gender:F
Credentials:NNP
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:300 W CLARENDON AVE STE 375
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85013-3476
Mailing Address - Country:US
Mailing Address - Phone:602-277-4161
Mailing Address - Fax:602-266-3481
Practice Address - Street 1:3003 E MCDOWELL RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85008-3620
Practice Address - Country:US
Practice Address - Phone:602-277-4161
Practice Address - Fax:602-266-3481
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-24
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZRN083714363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ146802Medicare PIN