Provider Demographics
NPI:1376565291
Name:HERRERO, TARA DUPUY (CRNA)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:DUPUY
Last Name:HERRERO
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 1:322 PLEASANT HILL RD
Mailing Address - Street 2:
Mailing Address - City:LANDRUM
Mailing Address - State:SC
Mailing Address - Zip Code:29356-8727
Mailing Address - Country:US
Mailing Address - Phone:864-468-5429
Mailing Address - Fax:
Practice Address - Street 1:1840 N JASPER DR STE 1
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-1634
Practice Address - Country:US
Practice Address - Phone:928-558-7001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2023-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2925652367500000X
AZ293397367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU2929ZMedicare PIN