Provider Demographics
NPI:1417979808
Name:BRYAN, TARA KELLY (CRNA)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:KELLY
Last Name:BRYAN
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 1:1890 LPGA BLVD
Mailing Address - Street 2:SUITE 210
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32117-7138
Mailing Address - Country:US
Mailing Address - Phone:386-274-1744
Mailing Address - Fax:386-274-1644
Practice Address - Street 1:1890 LPGA BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32117-7138
Practice Address - Country:US
Practice Address - Phone:386-274-1744
Practice Address - Fax:386-274-1644
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2010-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP3044612367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLG2019Medicare ID - Type Unspecified
FLG2019YMedicare UPIN