Provider Demographics
NPI:1629059548
Name:TAIT, JOE PARKER (CRNA)
Entity Type:Individual
Prefix:MR
First Name:JOE
Middle Name:PARKER
Last Name:TAIT
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 1:419 PR 7028
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON
Mailing Address - State:TX
Mailing Address - Zip Code:75657-5938
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1201 W FRANK AVE
Practice Address - Street 2:
Practice Address - City:LUFKIN
Practice Address - State:TX
Practice Address - Zip Code:75904-3357
Practice Address - Country:US
Practice Address - Phone:936-639-7900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-08
Last Update Date:2022-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA68603-02995163W00000X
TX670098163W00000X
TX47271367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1687243Medicaid
TX1687243Medicaid