Basic Information
| Provider Information | |||||||||
| NPI: | 1285022848 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WOMACK | ||||||||
| FirstName: | TASSI | ||||||||
| MiddleName: | MICHELLE | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3349 AMERICAN AVE STE C | ||||||||
| Address2: | |||||||||
| City: | JEFFERSON CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 651091080 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5736363483 | ||||||||
| FaxNumber: | 5736363386 | ||||||||
| Practice Location | |||||||||
| Address1: | 2505 MISSION DR | ||||||||
| Address2: | |||||||||
| City: | JEFFERSON CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 651099508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5736363483 | ||||||||
| FaxNumber: | 5736363386 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/06/2015 | ||||||||
| LastUpdateDate: | 06/09/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 2014044181 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.