Provider Demographics
NPI:1275772808
Name:CAUDILL, TARA JEAN (CRNA)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:JEAN
Last Name:CAUDILL
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8801 FALLS CHAPEL WAY
Mailing Address - Street 2:
Mailing Address - City:POTOMAC
Mailing Address - State:MD
Mailing Address - Zip Code:20854-2347
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:701 6TH ST S
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33701-4814
Practice Address - Country:US
Practice Address - Phone:727-823-2188
Practice Address - Fax:727-823-9502
Is Sole Proprietor?:No
Enumeration Date:2009-02-04
Last Update Date:2011-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9280286367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1942249271OtherGROUP NPI BAYFRONT ANESTHESIA SERVICE PA
FL000876700Medicaid
FLG4781OtherBCBS OF FL
FLP00887198OtherRR MCR ATTACHED TO GRP# CF4811
FLP00887198OtherRR MCR ATTACHED TO GRP# CF4811