Provider Demographics
NPI:1689110066
Name:COCKRUM, TASHA R (PA-C)
Entity Type:Individual
Prefix:
First Name:TASHA
Middle Name:R
Last Name:COCKRUM
Suffix:
Gender:F
Credentials:PA-C
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 1023
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97470-0232
Mailing Address - Country:US
Mailing Address - Phone:541-440-6390
Mailing Address - Fax:541-440-6392
Practice Address - Street 1:7585 N CEDAR AVE STE 102
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-2763
Practice Address - Country:US
Practice Address - Phone:559-243-1232
Practice Address - Fax:559-243-9954
Is Sole Proprietor?:No
Enumeration Date:2017-01-10
Last Update Date:2023-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA56921363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant