Provider Demographics
NPI:1659472256
Name:WITKOS, TARSILLA (CRNA)
Entity Type:Individual
Prefix:
First Name:TARSILLA
Middle Name:
Last Name:WITKOS
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:PO BOX 676
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ME
Mailing Address - Zip Code:04243-0676
Mailing Address - Country:US
Mailing Address - Phone:800-720-1664
Mailing Address - Fax:207-753-2020
Practice Address - Street 1:100 TER HEUN DR
Practice Address - Street 2:
Practice Address - City:FALMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02540
Practice Address - Country:US
Practice Address - Phone:508-548-5300
Practice Address - Fax:508-548-5789
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2007-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA163927367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00422245OtherRAILROAD MEDICARE