Basic Information
| Provider Information | |||||||||
| NPI: | 1235119017 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DWYER | ||||||||
| FirstName: | TANYA | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 530 | ||||||||
| Address2: | |||||||||
| City: | OLATHE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 814250530 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9703238703 | ||||||||
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| Practice Location | |||||||||
| Address1: | 800 S 3RD ST | ||||||||
| Address2: | |||||||||
| City: | MONTROSE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 814014212 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9702492211 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2006 | ||||||||
| LastUpdateDate: | 11/14/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 110448 | CO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 07110448 | 05 | CO | MEDICAID |