Basic Information
| Provider Information | |||||||||
| NPI: | 1932353315 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FRERKS | ||||||||
| FirstName: | TARA | ||||||||
| MiddleName: | LEE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3916 N INTERTECH CT | ||||||||
| Address2: | |||||||||
| City: | APPLETON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549136957 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9209961000 | ||||||||
| FaxNumber: | 9209961054 | ||||||||
| Practice Location | |||||||||
| Address1: | 3916 N INTERTECH CT | ||||||||
| Address2: | |||||||||
| City: | APPLETON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 54913 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9209961000 | ||||||||
| FaxNumber: | 9209961054 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/11/2008 | ||||||||
| LastUpdateDate: | 03/13/2019 | ||||||||
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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 | 207Q00000X | 32903 | SC | N | Allopathic & Osteopathic Physicians | Family Medicine | 207QS0010X | 32903 | SC | N | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine | 207Q00000X | 52283 | WI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 32903 | 01 | SC | SC MEDICAL LICENSE, MEDICAL BOARD | OTHER | 52283-020 | 01 | WI | WI LICENSE | OTHER |