Provider Demographics
NPI:1659697738
Name:BROWN, TARA RENEE
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:RENEE
Last Name:BROWN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:RENEE
Other - Last Name:GNUSCHKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5210 N BELT HWY
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MO
Mailing Address - Zip Code:64506-1211
Mailing Address - Country:US
Mailing Address - Phone:816-271-4996
Mailing Address - Fax:
Practice Address - Street 1:5210 N BELT HWY
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MO
Practice Address - Zip Code:64506-1211
Practice Address - Country:US
Practice Address - Phone:816-271-1330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-14
Last Update Date:2017-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013021958207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOP01230394OtherRR MEDICARE
KS201074810AMedicaid
MO1659697738Medicaid
MO1659697738Medicaid