Katherine Elaine Tavares, FNP-BC
Individual provider Active NPI Primary Care Nurse Practitioner · Peridot, AZ
NPI 1992433874 · NPPES record last updated Aug 16, 2022
Key facts
- NPI
- 1992433874
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Primary Care Nurse Practitioner 363LP2300X
- License
- 279367 (AZ)
- Practice address
- 103 Medicine Way Rd
Peridot, AZ 85542-5000 - Phone
- (928) 475-1400
- NPI assigned
- Aug 9, 2022
- Sex
- Female
- Sole proprietor
- No
Organizations & group practices 4
Hospital & facility affiliations 2
Medicare Care Compare profile
- Specialty
- Nurse Practitioner
- Education
- Other, 2022
- Medicare assignment
- Accepts the Medicare-approved amount as payment in full
- Group practices
- San Carlos Apache Healthcare Corporation
Practice addresses (Care Compare)
103 Medicine Way Rd
Peridot, AZ 85542-0787
Phone (928) 475-1400
Hospital & facility affiliations
- San Carlos Apache Healthcare Corporation
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in TX
- Eligible to order & refer
- Part B services: Yes · DME: Yes · Home health: Yes · Power mobility devices: Yes · Hospice: No
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20221011001458 | TX | Practitioner - Nurse Practitioner | 2961878251 | Reassigns benefits to 1 organization |
National Provider Directory
- Medicare enrollment (NPD)
- Yes
- Credentials
- Nurse Practitioner
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| RN105209 | AZ | MD | Registered Nurse |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| San Carlos Apache Healthcare Corporation | Current | Accepting new patients | |
| San Carlos Apache Healthcare Corporation | Current |
Accepting new patients |
Locations
103 Medicine Way Rd
Peridot, AZ 85542
Phone (928) 475-1200
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Registered Nurse | 163W00000X | RN105209 | AZ | |
| Primary Care Nurse Practitioner | 363LP2300X | 279367 | AZ | Yes |
Addresses
Primary practice location
103 Medicine Way Rd
Peridot, AZ 85542-5000
Mailing address
PO Box 2406
Claypool, AZ 85532-2406
Phone (928) 961-0159
Other providers in Peridot, AZ
- Jeffrey Standage
- Brenda Stevens
- Dorothea Blanche Stevens
- Nalani Ann Stevens
- Pamela N Tambi
- Sabra J Van Orsdol
- Mandy Vaughan
- Layla Rose Wall
- Jarell Lamonz Wilson
- Jessica Stella Wirtz
All providers in Peridot, AZ · Primary Care Nurse Practitioner in Arizona
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Aug 16, 2022. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Order and Referring (CMS).
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.