Provider Demographics
NPI:1891082020
Name:MAGGARD, TAMARA J (CRNA)
Entity type:Individual
Prefix:
First Name:TAMARA
Middle Name:J
Last Name:MAGGARD
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:TAMARA
Other - Middle Name:J
Other - Last Name:SHORTRIDGE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:PO BOX 2379
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:KY
Mailing Address - Zip Code:41105-2379
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2201 LEXINGTON AVE
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:KY
Practice Address - Zip Code:41101-2843
Practice Address - Country:US
Practice Address - Phone:606-408-4000
Practice Address - Fax:606-408-7426
Is Sole Proprietor?:No
Enumeration Date:2011-07-08
Last Update Date:2024-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV69920367500000X
KY3006732367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered