Provider Demographics
NPI:1134135056
Name:DOUGHERTY, KARA J (CRNA)
Entity Type:Individual
Prefix:
First Name:KARA
Middle Name:J
Last Name:DOUGHERTY
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:KARA
Other - Middle Name:J
Other - Last Name:FRIDLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:800 E 21ST ST
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57105-1016
Mailing Address - Country:US
Mailing Address - Phone:605-322-2754
Mailing Address - Fax:605-322-2727
Practice Address - Street 1:800 E 21ST ST
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-1016
Practice Address - Country:US
Practice Address - Phone:605-322-2754
Practice Address - Fax:605-322-2727
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2008-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDR027277367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN050K4FROtherMN BC PROVIDER #
NE46022474348Medicaid
SD9219544OtherDAKOTACARE PROVIDER #
IA0574269Medicaid
SD0041175OtherSD BC PROVIDER #
SD5753730Medicaid
SDS41175Medicare PIN
SD0041175OtherSD BC PROVIDER #