Provider Demographics
NPI:1780844332
Name:O'CONNOR, TARA C (ARNP)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:C
Last Name:O'CONNOR
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3930 SE DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202-1643
Mailing Address - Country:US
Mailing Address - Phone:503-418-3900
Mailing Address - Fax:503-418-3939
Practice Address - Street 1:3930 SE DIVISION ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-1643
Practice Address - Country:US
Practice Address - Phone:503-418-3900
Practice Address - Fax:503-418-3939
Is Sole Proprietor?:No
Enumeration Date:2008-06-16
Last Update Date:2012-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAN360139367363LP0808X
OR201250047NP363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8889815OtherMEDICARE PTAN
ORR163881Medicare PIN