Provider Demographics
NPI:1710231154
Name:TATARYN, GINA (LMT)
Entity Type:Individual
Prefix:MRS
First Name:GINA
Middle Name:
Last Name:TATARYN
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1875 GOLF COURSE RD S
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-9622
Mailing Address - Country:US
Mailing Address - Phone:503-400-6110
Mailing Address - Fax:
Practice Address - Street 1:300 GLEN CREEK RD NW
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97304-3058
Practice Address - Country:US
Practice Address - Phone:503-990-8627
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-07
Last Update Date:2015-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR19474225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist