Individual
ALISA TARASOVA
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
FNP
Contact information
Practice address
304 S 29TH ST, CHICKASHA, OK 73018-2501
(058) 968-0584
(855) 223-1999
Mailing address
PO BOX 929, CHICKASHA, OK 73023-0929
(405) 896-8058
(855) 223-1999
Taxonomy
Speciality
Code
Description
License number
State
363LF0000X
Family Nurse Practitioner
Primary
R0120108
OK
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
14383187
CAQH
OK
Enumeration date
12/20/2018
Last updated
11/21/2019
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