Provider Demographics
NPI:1194769109
Name:TAGUE, MONICA G (CRNA)
Entity type:Individual
Prefix:
First Name:MONICA
Middle Name:G
Last Name:TAGUE
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 1:2951 WEST FRONT STREET
Mailing Address - Street 2:SUITE 3050
Mailing Address - City:RICHLANDS
Mailing Address - State:VA
Mailing Address - Zip Code:24641
Mailing Address - Country:US
Mailing Address - Phone:276-963-8504
Mailing Address - Fax:276-963-6642
Practice Address - Street 1:2949 WEST FRONT STREET
Practice Address - Street 2:
Practice Address - City:RICHLANDS
Practice Address - State:VA
Practice Address - Zip Code:24641
Practice Address - Country:US
Practice Address - Phone:276-596-6000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-16
Last Update Date:2013-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024083585367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA008932221Medicaid
VA430064722OtherRR MEDICARE
VA0069719-000OtherWV MEDICAID
R10101Medicare UPIN
VA008932221Medicaid