Provider Demographics
NPI:1346527728
Name:WILSON, TAMMY LEIGH (PA-C)
Entity Type:Individual
Prefix:
First Name:TAMMY
Middle Name:LEIGH
Last Name:WILSON
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 1:6464 SW BORLAND RD
Mailing Address - Street 2:SUITE C-4
Mailing Address - City:TUALATIN
Mailing Address - State:OR
Mailing Address - Zip Code:97062-8876
Mailing Address - Country:US
Mailing Address - Phone:503-885-7770
Mailing Address - Fax:503-961-8454
Practice Address - Street 1:6464 SW BORLAND RD
Practice Address - Street 2:SUITE C-4
Practice Address - City:TUALATIN
Practice Address - State:OR
Practice Address - Zip Code:97062-8876
Practice Address - Country:US
Practice Address - Phone:503-885-7770
Practice Address - Fax:503-961-8454
Is Sole Proprietor?:No
Enumeration Date:2011-11-13
Last Update Date:2011-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA156635363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant