Provider Demographics
NPI:1144045444
Name:PETERSON, TARA (APNP)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:APNP
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:
Other - Last Name:CARSTENS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10001 W INNOVATION DR STE 200
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-4851
Mailing Address - Country:US
Mailing Address - Phone:888-838-3838
Mailing Address - Fax:888-919-1083
Practice Address - Street 1:2654 S ONEIDA ST STOP 102
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54304-5337
Practice Address - Country:US
Practice Address - Phone:888-938-3838
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-21
Last Update Date:2024-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI197282-30163W00000X
WI15899-33363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse