Basic Information
| Provider Information | |||||||||
| NPI: | 1992035778 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SANDS | ||||||||
| FirstName: | TARA | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | DNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HYTREK | ||||||||
| OtherFirstName: | TARA | ||||||||
| OtherMiddleName: | L. | ||||||||
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| OtherCredential: | DNP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 7261 MERCY RD | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681242311 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3135 W BROADWAY | ||||||||
| Address2: | |||||||||
| City: | COUNCIL BLUFFS | ||||||||
| State: | IA | ||||||||
| PostalCode: | 51501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7123289100 | ||||||||
| FaxNumber: | 7123280095 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/30/2009 | ||||||||
| LastUpdateDate: | 11/06/2018 | ||||||||
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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 | 363L00000X | 111084 | NE | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363L00000X | A123906 | IA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.