Provider Demographics
NPI:1760981997
Name:GORDON, TARA L (APRN, FNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:TARA
Middle Name:L
Last Name:GORDON
Suffix:
Gender:F
Credentials:APRN, FNP-BC
Other - Prefix:MISS
Other - First Name:TARA
Other - Middle Name:L
Other - Last Name:CARROLL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:12403 ALTAMIRA ST
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78748-4038
Mailing Address - Country:US
Mailing Address - Phone:419-460-2476
Mailing Address - Fax:
Practice Address - Street 1:12403 ALTAMIRA ST
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78748-4038
Practice Address - Country:US
Practice Address - Phone:419-460-2476
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-02
Last Update Date:2018-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF12170077363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily