Provider Demographics
NPI:1821290743
Name:GONZALEZ, TARIS (NP)
Entity Type:Individual
Prefix:
First Name:TARIS
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8391 S SHADY TRAIL DR
Mailing Address - Street 2:
Mailing Address - City:PENDLETON
Mailing Address - State:IN
Mailing Address - Zip Code:46064-8652
Mailing Address - Country:US
Mailing Address - Phone:317-743-0009
Mailing Address - Fax:
Practice Address - Street 1:8391 S SHADY TRAIL DR
Practice Address - Street 2:
Practice Address - City:PENDLETON
Practice Address - State:IN
Practice Address - Zip Code:46064-8652
Practice Address - Country:US
Practice Address - Phone:317-507-2395
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-04
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71001601363LA2100X
IN71001601A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP01170026OtherRR MEDICARE PTAN
IN200460280Medicaid
IN200460280Medicaid