Provider Demographics
NPI:1619313459
Name:GRGURICH, TARA MACSEENE (CRNA)
Entity Type:Individual
Prefix:MRS
First Name:TARA
Middle Name:MACSEENE
Last Name:GRGURICH
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 1:1104 N BALTIMORE ST
Mailing Address - Street 2:
Mailing Address - City:KIRKSVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63501-2528
Mailing Address - Country:US
Mailing Address - Phone:660-216-9300
Mailing Address - Fax:
Practice Address - Street 1:14288 SHIBLEY RD
Practice Address - Street 2:
Practice Address - City:GREEN CASTLE
Practice Address - State:MO
Practice Address - Zip Code:63544-3141
Practice Address - Country:US
Practice Address - Phone:660-488-6598
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-20
Last Update Date:2022-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013012835367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered