Provider Demographics
NPI:1609837350
Name:TADLOCK, MICHAEL E (CRNA)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:E
Last Name:TADLOCK
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:916 4TH AVE. SW
Mailing Address - Street 2:
Mailing Address - City:PIPESTONE
Mailing Address - State:MN
Mailing Address - Zip Code:56164
Mailing Address - Country:US
Mailing Address - Phone:507-825-5811
Mailing Address - Fax:563-556-8334
Practice Address - Street 1:916 4TH AVE. SW
Practice Address - Street 2:
Practice Address - City:PIPESTONE
Practice Address - State:MN
Practice Address - Zip Code:56164
Practice Address - Country:US
Practice Address - Phone:507-825-5811
Practice Address - Fax:563-556-8334
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2014-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAD103531367500000X
MN223779-0367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0453241Medicaid
WI44335300Medicaid
WI44335300Medicaid
IL$$$$$$$$$Medicaid
IAI14268Medicare PIN