Provider Demographics
NPI:1740792522
Name:EVANS, TARA RAE (NP-C)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:RAE
Last Name:EVANS
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5919 BRIGHAM RD
Mailing Address - Street 2:
Mailing Address - City:GOODRICH
Mailing Address - State:MI
Mailing Address - Zip Code:48438-9646
Mailing Address - Country:US
Mailing Address - Phone:248-240-6918
Mailing Address - Fax:
Practice Address - Street 1:612 N STATE RD
Practice Address - Street 2:
Practice Address - City:DAVISON
Practice Address - State:MI
Practice Address - Zip Code:48423-3505
Practice Address - Country:US
Practice Address - Phone:810-652-6600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-01
Last Update Date:2017-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704301205363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily