Basic Information
Provider Information | |||||||||
NPI: | 1558379156 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BENDER | ||||||||
FirstName: | TINA | ||||||||
MiddleName: | M | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | CRNA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | MEJIA | ||||||||
OtherFirstName: | TINA | ||||||||
OtherMiddleName: | MARIE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | CRNA | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 3181 SW SAM JACKSON PARK RD | ||||||||
Address2: | MAIL CODE SJH-2 | ||||||||
City: | PORTLAND | ||||||||
State: | OR | ||||||||
PostalCode: | 972393011 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5034944910 | ||||||||
FaxNumber: | 5034948368 | ||||||||
Practice Location | |||||||||
Address1: | 3181 SW SAM JACKSON PARK RD | ||||||||
Address2: |   | ||||||||
City: | PORTLAND | ||||||||
State: | OR | ||||||||
PostalCode: | 972393011 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5034947641 | ||||||||
FaxNumber: | 5034948368 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/03/2006 | ||||||||
LastUpdateDate: | 12/01/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 201508460RN | OR | N |   | Nursing Service Providers | Registered Nurse |   | 163W00000X | RN. 0103612 | CO | N |   | Nursing Service Providers | Registered Nurse |   | 367500000X | 0004560CRNA | CO | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   | 367500000X | 201508486CRNA | OR | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   |
ID Information
ID | Type | State | Issuer | Description | 0004560 | 01 | CO | CRNA CO | OTHER | C801056 | 01 | CO | MEDICARE ID | OTHER | 1558379156 | 01 |   | NPI | OTHER | 03178820 | 05 | CO |   | MEDICAID | 201508486 | 01 | OR | CRNA | OTHER |