Provider Demographics
NPI:1710353560
Name:PETERSON, TARA ANNE (PNP)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:ANNE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 N PROSPECT AVE APT 211
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53202-3045
Mailing Address - Country:US
Mailing Address - Phone:720-320-0790
Mailing Address - Fax:
Practice Address - Street 1:13950 W CAPITOL DR STE 200
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-2441
Practice Address - Country:US
Practice Address - Phone:262-781-3065
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-17
Last Update Date:2015-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6541-33363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics