Provider Demographics
NPI:1639280985
Name:PERDUE, TARA S (APRN)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:S
Last Name:PERDUE
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 PARK ST
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42101-1759
Mailing Address - Country:US
Mailing Address - Phone:270-586-9533
Mailing Address - Fax:270-586-0123
Practice Address - Street 1:119 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:KY
Practice Address - Zip Code:42134-2752
Practice Address - Country:US
Practice Address - Phone:270-586-9533
Practice Address - Fax:270-586-0123
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2018-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3003086363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY78003217Medicaid
KY7800321700Medicaid
KYS97683Medicare UPIN
KY0930001Medicare PIN