Provider Demographics
NPI:1639123599
Name:LUBKIN, TANYA M (DO)
Entity Type:Individual
Prefix:
First Name:TANYA
Middle Name:M
Last Name:LUBKIN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:TANYA
Other - Middle Name:
Other - Last Name:SLICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:PO BOX 3158
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3158
Mailing Address - Country:US
Mailing Address - Phone:503-215-6494
Mailing Address - Fax:503-215-6644
Practice Address - Street 1:12442 SW SCHOLLS FERRY RD
Practice Address - Street 2:SUITE 100
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-3396
Practice Address - Country:US
Practice Address - Phone:503-216-9900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2012-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO25113207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORP00171596OtherRR MEDICARE
OR232436Medicaid
ORR160993Medicare PIN
ORR159638Medicare PIN
ORI10290Medicare UPIN
ORR131820Medicare PIN
ORP00171596OtherRR MEDICARE