Provider Demographics
NPI:1508830571
Name:GARDNER-BROWN, TARA (NP-C)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:GARDNER-BROWN
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1880 SW 6TH AVE STE 200
Mailing Address - Street 2:PORTLAND STATE UNIVERSITY
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97201-5204
Mailing Address - Country:US
Mailing Address - Phone:503-725-2800
Mailing Address - Fax:
Practice Address - Street 1:1880 SW 6TH AVE STE 200
Practice Address - Street 2:PORTLAND STATE UNIVERSITY
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97201-5204
Practice Address - Country:US
Practice Address - Phone:503-725-2800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2016-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201250044NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806098000Medicaid
P38667Medicare UPIN
ID806098000Medicaid