Provider Demographics
NPI:1235459041
Name:CASTILLO, TARRA LYNNE (CNM, NMNP)
Entity Type:Individual
Prefix:
First Name:TARRA
Middle Name:LYNNE
Last Name:CASTILLO
Suffix:
Gender:F
Credentials:CNM, NMNP
Other - Prefix:
Other - First Name:TARRA
Other - Middle Name:LYNNE
Other - Last Name:KELLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNM, NMNP
Mailing Address - Street 1:PO BOX 6149
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97007-0149
Mailing Address - Country:US
Mailing Address - Phone:503-352-8642
Mailing Address - Fax:503-352-8658
Practice Address - Street 1:333 SE 7TH AVE STE 5500
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97123-4185
Practice Address - Country:US
Practice Address - Phone:503-597-4500
Practice Address - Fax:505-974-5015
Is Sole Proprietor?:No
Enumeration Date:2010-06-03
Last Update Date:2018-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60125680367A00000X
OR201050062NP367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500634641Medicaid
WA1235459041Medicaid