Healthcare Provider Details

I. General information

NPI: 1710431309
Provider Name (Legal Business Name): ROGER TATARIAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2016
Last Update Date: 01/23/2024
Certification Date: 01/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1818 N MEADE ST
APPLETON WI
54911-3454
US

IV. Provider business mailing address

203 DESPLAINE RD
DE PERE WI
54115-3726
US

V. Phone/Fax

Practice location:
  • Phone: 920-731-4101
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number200090-30
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: