Basic Information
| Provider Information | |||||||||
| NPI: | 1558894329 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PALMER | ||||||||
| FirstName: | TARA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3290 | ||||||||
| Address2: | |||||||||
| City: | LA GRANDE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 978507290 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5416637313 | ||||||||
| FaxNumber: | 5419755120 | ||||||||
| Practice Location | |||||||||
| Address1: | 506 4TH ST | ||||||||
| Address2: | |||||||||
| City: | LA GRANDE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 978501906 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5416633138 | ||||||||
| FaxNumber: | 5419755120 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/07/2017 | ||||||||
| LastUpdateDate: | 08/14/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 1-089967 | AL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | 201910351NP-PP | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 500773203 | 05 | OR | MEDICAID |