Provider Demographics
NPI:1508951864
Name:PASSALARIS, TINA MARINA (MD)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:MARINA
Last Name:PASSALARIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1189
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97339-1189
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:501 NW ELKS DR STE 100
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-3757
Practice Address - Country:US
Practice Address - Phone:541-768-4950
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2021-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00032741207RX0202X
ORMD179486207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
H24169Medicare UPIN