Provider Demographics
NPI:1912930090
Name:HANCOCK, TARA M (CRNA)
Entity Type:Individual
Prefix:MRS
First Name:TARA
Middle Name:M
Last Name:HANCOCK
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 1:68 S SERVICE RD
Mailing Address - Street 2:SUITE 350
Mailing Address - City:MELVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11747-2358
Mailing Address - Country:US
Mailing Address - Phone:516-945-3000
Mailing Address - Fax:516-945-3131
Practice Address - Street 1:500 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:WARRENTON
Practice Address - State:VA
Practice Address - Zip Code:20186-3027
Practice Address - Country:US
Practice Address - Phone:540-316-5703
Practice Address - Fax:540-316-5701
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2015-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024166874367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA139698OtherANTHEM
VA484645OtherNCPPO
VA1912930090Medicaid
DCK142-0002OtherCAREFIRST
VA139698OtherANTHEM
VA484645OtherNCPPO