Provider Demographics
NPI:1194792093
Name:GENTLE, TAMARA HEGLAR (NP)
Entity type:Individual
Prefix:
First Name:TAMARA
Middle Name:HEGLAR
Last Name:GENTLE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:TAMARA
Other - Middle Name:HEGLAR
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7004 SMITH CORNERS BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28269-3827
Mailing Address - Country:US
Mailing Address - Phone:704-688-9650
Mailing Address - Fax:704-688-9651
Practice Address - Street 1:1000 COPPERFIELD BLVD NE STE 124
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-2454
Practice Address - Country:US
Practice Address - Phone:704-688-9641
Practice Address - Fax:704-960-4817
Is Sole Proprietor?:No
Enumeration Date:2006-03-01
Last Update Date:2023-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC900457363LA2200X
NC95127363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1194792093Medicaid
NCNCB984AOtherMEDICARE PTAN INDIVIDUAL, EFF 2/23/13
NC566000156OtherOCCUPATIONAL MED TAX ID
NC1194792093Medicaid
NCNCB984EMedicare PIN
NCNCB984CMedicare PIN
NCQ35278Medicare UPIN
NCNCB984BMedicare PIN
NC566000156OtherOCCUPATIONAL MED TAX ID
NCNCB984AOtherMEDICARE PTAN INDIVIDUAL, EFF 2/23/13
NC2592308Medicare PIN
NCNCB984DMedicare PIN