Provider Demographics
NPI:1578066320
Name:SUTHERLAND, TARA A (DO)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:A
Last Name:SUTHERLAND
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7315 212TH ST SW
Mailing Address - Street 2:SUITE 101/207
Mailing Address - City:EDMONDS
Mailing Address - State:WA
Mailing Address - Zip Code:98026
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 MULLINS DR
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:OR
Practice Address - Zip Code:97355-3983
Practice Address - Country:US
Practice Address - Phone:949-351-7855
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-16
Last Update Date:2024-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WAOP61460093207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program