Provider Demographics
NPI:1316237084
Name:POPKES, TARA L (CRNA)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:L
Last Name:POPKES
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:L
Other - Last Name:KELLENBERGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:PO BOX 5045
Mailing Address - Street 2:ATTN: C.B.O. PROV ENROLLMT
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-5045
Mailing Address - Country:US
Mailing Address - Phone:605-322-6428
Mailing Address - Fax:
Practice Address - Street 1:1325 S CLIFF AVE
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-1007
Practice Address - Country:US
Practice Address - Phone:605-322-2754
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-14
Last Update Date:2014-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDCR000760367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1316237084Medicaid
9304223OtherDAKOTACARE
NE46022474348Medicaid
SD5757490Medicaid
1316237084OtherBCBS MN
1316237084OtherWELLMARK BCBS
MN1316237084Medicaid
SDS104923Medicare PIN