Provider Demographics
NPI:1457353120
Name:TAGGART, JACK (CRNA)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:TAGGART
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 1:3320 TATES CREEK RD
Mailing Address - Street 2:SUITE 204
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40502-3400
Mailing Address - Country:US
Mailing Address - Phone:859-268-1030
Mailing Address - Fax:859-269-4120
Practice Address - Street 1:1600 SW ARCHER RD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32610-6514
Practice Address - Country:US
Practice Address - Phone:352-273-8610
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2023-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN9303664367500000X
KY4226A367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY74007352Medicaid
FL113064500Medicaid