Provider Demographics
NPI:1124420237
Name:WAFZIG, TARAH D (APRN-NP)
Entity type:Individual
Prefix:
First Name:TARAH
Middle Name:D
Last Name:WAFZIG
Suffix:
Gender:F
Credentials:APRN-NP
Other - Prefix:
Other - First Name:TARAH
Other - Middle Name:D
Other - Last Name:ROBISON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:100 E LIBERTY ST
Mailing Address - Street 2:SUITE 800
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-1434
Mailing Address - Country:US
Mailing Address - Phone:502-543-4119
Mailing Address - Fax:502-543-1462
Practice Address - Street 1:187 ADAM SHEPHERD PKWY STE 5
Practice Address - Street 2:
Practice Address - City:SHEPHERDSVILLE
Practice Address - State:KY
Practice Address - Zip Code:40165-7500
Practice Address - Country:US
Practice Address - Phone:502-543-4119
Practice Address - Fax:502-543-1462
Is Sole Proprietor?:No
Enumeration Date:2014-09-19
Last Update Date:2018-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3008895363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100365350Medicaid
KY7100365350Medicaid
KYK167610Medicare PIN