Provider Demographics
NPI:1063463362
Name:TARP, CLARENCE DALLAS (CRNA)
Entity Type:Individual
Prefix:MR
First Name:CLARENCE
Middle Name:DALLAS
Last Name:TARP
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:CLARENCE
Other - Middle Name:
Other - Last Name:TARP
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3206 CALIENTE CT
Mailing Address - Street 2:#6184
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76017-2504
Mailing Address - Country:US
Mailing Address - Phone:870-918-4460
Mailing Address - Fax:
Practice Address - Street 1:515 S 7TH ST
Practice Address - Street 2:
Practice Address - City:MCALESTER
Practice Address - State:OK
Practice Address - Zip Code:74501-5915
Practice Address - Country:US
Practice Address - Phone:870-918-4460
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2013-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARCOO447367500000X
ARR28256367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK103674701Medicaid
AK103674701Medicaid