Provider Demographics
NPI:1063404010
Name:IRELAND, TAMARA CHRISTINE (CRNA)
Entity type:Individual
Prefix:
First Name:TAMARA
Middle Name:CHRISTINE
Last Name:IRELAND
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:TAMARA
Other - Middle Name:CHRISTINE
Other - Last Name:SCOTT-GANTZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:1 MEDICAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:BIDDEFORD
Mailing Address - State:ME
Mailing Address - Zip Code:04005-9422
Mailing Address - Country:US
Mailing Address - Phone:207-283-7042
Mailing Address - Fax:207-283-7047
Practice Address - Street 1:1 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:BIDDEFORD
Practice Address - State:ME
Practice Address - Zip Code:04005-9422
Practice Address - Country:US
Practice Address - Phone:207-283-7042
Practice Address - Fax:207-283-7047
Is Sole Proprietor?:No
Enumeration Date:2005-08-16
Last Update Date:2019-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT066334163W00000X
ARC01203367500000X
MERNA83338367500000X
CT002528367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5U902OtherAR BLUE CROSS BLUE SHIELD
AR142730701Medicaid
ME1063404010Medicaid
MERNA83338OtherLICENSE