Provider Demographics
NPI:1275803462
Name:PEMBERTON, TARA (PA-C)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:PEMBERTON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9495SWLOCUST ST A
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97223-6683
Mailing Address - Country:US
Mailing Address - Phone:503-636-9011
Mailing Address - Fax:503-636-3952
Practice Address - Street 1:9495 SW LOCUST ST
Practice Address - Street 2:SUITE A & E
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97223-6683
Practice Address - Country:US
Practice Address - Phone:503-505-5937
Practice Address - Fax:503-505-5922
Is Sole Proprietor?:No
Enumeration Date:2012-01-05
Last Update Date:2015-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500643737Medicaid
WAG8908654Medicare PIN
OR500643737Medicaid