Provider Demographics
NPI:1346202892
Name:GLASGOW, TARA S (CRNA)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:S
Last Name:GLASGOW
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 1:701 N 1ST ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62781-0001
Mailing Address - Country:US
Mailing Address - Phone:217-788-3754
Mailing Address - Fax:217-788-7071
Practice Address - Street 1:701 N 1ST ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62781-0001
Practice Address - Country:US
Practice Address - Phone:217-788-3754
Practice Address - Fax:217-788-7071
Is Sole Proprietor?:No
Enumeration Date:2006-04-03
Last Update Date:2008-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209000194367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
047565OtherCCNA CERTIFICATION
IL041276945OtherRN LICENSE
047565OtherCCNA CERTIFICATION
ILS40844Medicare UPIN
IL041276945OtherRN LICENSE