Provider Demographics
NPI:1972972446
Name:TARTER FAMILY MEDICINE INC
Entity Type:Organization
Organization Name:TARTER FAMILY MEDICINE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAN
Authorized Official - Middle Name:
Authorized Official - Last Name:TARTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-880-8919
Mailing Address - Street 1:1560 N CRESTMONT DR STE A
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-2178
Mailing Address - Country:US
Mailing Address - Phone:208-650-4888
Mailing Address - Fax:208-650-4892
Practice Address - Street 1:1560 N CRESTMONT DR STE A
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-2178
Practice Address - Country:US
Practice Address - Phone:208-650-4888
Practice Address - Fax:208-650-4892
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-15
Last Update Date:2018-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP439A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1275631244OtherINDIVIDUAL NPI