Provider Demographics
NPI:1811074529
Name:BUCK, TARA CHRISTINE (ARNP)
Entity type:Individual
Prefix:MRS
First Name:TARA
Middle Name:CHRISTINE
Last Name:BUCK
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:CHRISTINE
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ARNP
Mailing Address - Street 1:910 MALABAR RD SE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32907-3200
Mailing Address - Country:US
Mailing Address - Phone:321-768-2356
Mailing Address - Fax:321-726-6388
Practice Address - Street 1:910 MALABAR RD SE
Practice Address - Street 2:SUITE 2
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32907-3200
Practice Address - Country:US
Practice Address - Phone:321-768-2356
Practice Address - Fax:321-726-6388
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP3312942363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLQ13501Medicare ID - Type Unspecified
FLQ13501Medicare UPIN