Provider Demographics
NPI:1861417909
Name:GALLAGHER TATARU, COLLEEN G (CRNA)
Entity type:Individual
Prefix:
First Name:COLLEEN
Middle Name:G
Last Name:GALLAGHER TATARU
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38401 MENTOR AVE.
Mailing Address - Street 2:UNIT 7301
Mailing Address - City:WILLOUGHBY
Mailing Address - State:OH
Mailing Address - Zip Code:44094-1912
Mailing Address - Country:US
Mailing Address - Phone:440-478-9340
Mailing Address - Fax:
Practice Address - Street 1:38401 MENTOR AVE.
Practice Address - Street 2:UNIT 7301
Practice Address - City:WILLOUGHBY
Practice Address - State:OH
Practice Address - Zip Code:44094-1912
Practice Address - Country:US
Practice Address - Phone:440-478-9340
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2018-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN179085367500000X
WV101340367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI104335207OtherMICHIGAN MEDICAID
OH341877986020OtherMMO
OH000000230250OtherANTHEM
OH430055991OtherRAILROAD MEDICARE
OH341877986019OtherMMO
OH0927662Medicaid
OH000000230250OtherANTHEM
OH8225923Medicare ID - Type UnspecifiedOHIO MEDICARE