Provider Demographics
NPI:1558379156
Name:BENDER, TINA M (CRNA)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:M
Last Name:BENDER
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:TINA
Other - Middle Name:MARIE
Other - Last Name:MEJIA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:3181 SW SAM JACKSON PARK RD
Mailing Address - Street 2:MAIL CODE SJH-2
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-3011
Mailing Address - Country:US
Mailing Address - Phone:503-494-4910
Mailing Address - Fax:503-494-8368
Practice Address - Street 1:3181 SW SAM JACKSON PARK RD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-3011
Practice Address - Country:US
Practice Address - Phone:503-494-7641
Practice Address - Fax:503-494-8368
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2017-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201508460RN163W00000X
CORN. 0103612163W00000X
CO0004560CRNA367500000X
OR201508486CRNA367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO0004560OtherCRNA CO
COC801056OtherMEDICARE ID
1558379156OtherNPI
CO03178820Medicaid
OR201508486OtherCRNA
CO03178820Medicaid