Basic Information
| Provider Information | |||||||||
| NPI: | 1255565776 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MEBIUS | ||||||||
| FirstName: | TARA | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1325 S CLIFF AVE | ||||||||
| Address2: | PO BOX 5045 | ||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571051007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6053222754 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1325 S CLIFF AVE | ||||||||
| Address2: | |||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571051007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6053222754 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2009 | ||||||||
| LastUpdateDate: | 12/31/2014 | ||||||||
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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 | SD-CRNA CR000723 | SD | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 1255565776 | 01 | MN BCBS | OTHER | P00734924 | 01 | RAILROAD MEDICARE | OTHER | 46022474348 | 05 | NE | MEDICAID | 9280534 | 01 | DAKOTACARE | OTHER | 5756300 | 05 | SD | MEDICAID | 1255565776 | 05 | MN | MEDICAID | 1255565776 | 01 | WELLMARK BCBS-SD | OTHER |