Provider Demographics
NPI:1437480068
Name:CROSSLAN, TARA
Entity Type:Individual
Prefix:MS
First Name:TARA
Middle Name:
Last Name:CROSSLAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:610 E 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99501-2731
Mailing Address - Country:US
Mailing Address - Phone:907-258-3498
Mailing Address - Fax:907-279-0171
Practice Address - Street 1:542 4TH AVE
Practice Address - Street 2:SUITE 234
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-4714
Practice Address - Country:US
Practice Address - Phone:907-456-4524
Practice Address - Fax:907-456-5524
Is Sole Proprietor?:No
Enumeration Date:2010-01-21
Last Update Date:2010-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKCM0115Medicaid