Basic Information
| Provider Information | |||||||||
| NPI: | 1043394844 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHAVIS | ||||||||
| FirstName: | TARA | ||||||||
| MiddleName: | ROSE | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | APRN-CNP, WHNP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 825 NE 10TH ST | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731045417 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 825 NE 10TH ST | ||||||||
| Address2: | SUITE 3300 | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731045417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052715239 | ||||||||
| FaxNumber: | 4052713727 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2006 | ||||||||
| LastUpdateDate: | 03/05/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LW0102X | R0062577 | OK | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Women's Health |
ID Information
| ID | Type | State | Issuer | Description | 200473900 A | 05 | OK | MEDICAID |