Provider Demographics
NPI:1962402362
Name:TATUM, CAROL A (ANP CNS)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:A
Last Name:TATUM
Suffix:
Gender:F
Credentials:ANP CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5002 COWHORN CREEK RD
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75503-9766
Mailing Address - Country:US
Mailing Address - Phone:903-614-3000
Mailing Address - Fax:903-614-3525
Practice Address - Street 1:1902 GALLERIA OAKS DR
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-4619
Practice Address - Country:US
Practice Address - Phone:903-614-3800
Practice Address - Fax:903-614-3525
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2007-07-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TX526526364SP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
S14811Medicare UPIN
TX82N377Medicare ID - Type Unspecified