Basic Information
| Provider Information | |||||||||
| NPI: | 1376976332 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PEACOCK | ||||||||
| FirstName: | TARA | ||||||||
| MiddleName: | N | ||||||||
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| Credential: | CNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2925 CHICAGO AVE | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554071321 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6122625000 | ||||||||
| FaxNumber: | 6122624258 | ||||||||
| Practice Location | |||||||||
| Address1: | 1021 BANDANA BLVD E | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | SAINT PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551085113 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512419700 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/14/2013 | ||||||||
| LastUpdateDate: | 03/03/2014 | ||||||||
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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 | 363LA2200X | R1753372 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
No ID Information.