Healthcare Provider Details

I. General information

NPI: 1619313459
Provider Name (Legal Business Name): TARA MACSEENE GRGURICH CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2013
Last Update Date: 10/05/2022
Certification Date: 03/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14288 SHIBLEY RD
GREEN CASTLE MO
63544-3141
US

IV. Provider business mailing address

1104 N BALTIMORE ST
KIRKSVILLE MO
63501-2528
US

V. Phone/Fax

Practice location:
  • Phone: 660-488-6598
  • Fax:
Mailing address:
  • Phone: 660-216-9300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number2013012835
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: