Basic Information
| Provider Information | |||||||||
| NPI: | 1780844332 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | O'CONNOR | ||||||||
| FirstName: | TARA | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3930 SE DIVISION ST | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972021643 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034183900 | ||||||||
| FaxNumber: | 5034183939 | ||||||||
| Practice Location | |||||||||
| Address1: | 3930 SE DIVISION ST | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972021643 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034183900 | ||||||||
| FaxNumber: | 5034183939 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2008 | ||||||||
| LastUpdateDate: | 07/17/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | N360139367 | WA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 363LP0808X | 201250047NP | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | G8889815 | 01 | WA | MEDICARE PTAN | OTHER |