Basic Information
| Provider Information | |||||||||
| NPI: | 1962174953 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HERDEGEN | ||||||||
| FirstName: | TARAH | ||||||||
| MiddleName: | LYNN | ||||||||
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| Credential: | FNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9850 W ST LUKES DR STE 180 | ||||||||
| Address2: | |||||||||
| City: | NAMPA | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836877912 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083221680 | ||||||||
| FaxNumber: | 2084618194 | ||||||||
| Practice Location | |||||||||
| Address1: | 9850 W ST LUKES DR STE 180 | ||||||||
| Address2: | |||||||||
| City: | NAMPA | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836877912 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083221680 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2021 | ||||||||
| LastUpdateDate: | 04/26/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/26/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 00000 | ID | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | 55734 | ID | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.