Provider Demographics
NPI:1710288105
Name:RACZKA, TARA S, (FNP-C)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:S,
Last Name:RACZKA
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 38
Mailing Address - Street 2:
Mailing Address - City:SACATON
Mailing Address - State:AZ
Mailing Address - Zip Code:85147-0001
Mailing Address - Country:US
Mailing Address - Phone:520-550-6000
Mailing Address - Fax:520-550-6032
Practice Address - Street 1:438 W. SEED FARM RD
Practice Address - Street 2:
Practice Address - City:SACATON
Practice Address - State:AZ
Practice Address - Zip Code:85147-0038
Practice Address - Country:US
Practice Address - Phone:520-550-6000
Practice Address - Fax:520-550-6032
Is Sole Proprietor?:No
Enumeration Date:2010-11-16
Last Update Date:2013-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP4566363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily