Basic Information
| Provider Information | |||||||||
| NPI: | 1205893567 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRAKKE | ||||||||
| FirstName: | TARA | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 988102 NEBRASKA MEDICAL CTR | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681988102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4025594081 | ||||||||
| FaxNumber: | 4025597372 | ||||||||
| Practice Location | |||||||||
| Address1: | 988102 NEBRASKA MEDICAL CTR | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681988102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4025594081 | ||||||||
| FaxNumber: | 4025597372 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/28/2006 | ||||||||
| LastUpdateDate: | 06/20/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 22005 | NE | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 47078557501 | 05 | NE | MEDICAID |