Provider Demographics
NPI:1740407683
Name:KIRKPATRICK GRAHAM, TARA S (NNP)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:S
Last Name:KIRKPATRICK GRAHAM
Suffix:
Gender:F
Credentials:NNP
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:S
Other - Last Name:KIRKPATRICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NNP
Mailing Address - Street 1:2801 N GANTENBEIN AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97227-1623
Mailing Address - Country:US
Mailing Address - Phone:503-413-1867
Mailing Address - Fax:503-413-2580
Practice Address - Street 1:2801 N GANTENBEIN AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97227-1623
Practice Address - Country:US
Practice Address - Phone:503-413-1867
Practice Address - Fax:503-413-2580
Is Sole Proprietor?:No
Enumeration Date:2007-04-20
Last Update Date:2013-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200650152NP363LN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR271141Medicaid