Provider Demographics
NPI:1023160330
Name:HOLDER, TARA M (APRN, ENP, FNP)
Entity type:Individual
Prefix:MRS
First Name:TARA
Middle Name:M
Last Name:HOLDER
Suffix:
Gender:F
Credentials:APRN, ENP, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:755 N 11TH STREET
Mailing Address - Street 2:SUITE P-5200
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77702-1522
Mailing Address - Country:US
Mailing Address - Phone:409-898-2994
Mailing Address - Fax:409-899-5542
Practice Address - Street 1:755 N 11TH STREET
Practice Address - Street 2:SUITE P-5200
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77702-1522
Practice Address - Country:US
Practice Address - Phone:409-898-2994
Practice Address - Fax:409-899-5542
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2015-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX660917363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX7702695OtherAETNA
TX1658650-01Medicaid
TXP00141387OtherRAILROAD MEDICARE
TX8N6091OtherBLUE CROSS BLUE SHIELD
TX7702695OtherAETNA
TX8N6091OtherBLUE CROSS BLUE SHIELD