Provider Demographics
NPI:1043782634
Name:TARASOVA, ALISA (FNP)
Entity Type:Individual
Prefix:
First Name:ALISA
Middle Name:
Last Name:TARASOVA
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 929
Mailing Address - Street 2:
Mailing Address - City:CHICKASHA
Mailing Address - State:OK
Mailing Address - Zip Code:73023-0929
Mailing Address - Country:US
Mailing Address - Phone:405-896-8058
Mailing Address - Fax:855-223-1999
Practice Address - Street 1:304 S 29TH ST
Practice Address - Street 2:
Practice Address - City:CHICKASHA
Practice Address - State:OK
Practice Address - Zip Code:73018-2501
Practice Address - Country:US
Practice Address - Phone:058-968-0584
Practice Address - Fax:855-223-1999
Is Sole Proprietor?:No
Enumeration Date:2018-12-20
Last Update Date:2019-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0120108363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK14383187OtherCAQH