Provider Demographics
NPI:1821096116
Name:PINSKE BACKUS, TARA LYNN (OD)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:LYNN
Last Name:PINSKE BACKUS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19171 SE MILL PLAIN BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-9321
Mailing Address - Country:US
Mailing Address - Phone:360-254-1026
Mailing Address - Fax:360-256-2318
Practice Address - Street 1:19171 SE MILL PLAIN BLVD
Practice Address - Street 2:STE 101
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98683-9321
Practice Address - Country:US
Practice Address - Phone:360-254-1026
Practice Address - Fax:360-256-2318
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-11
Last Update Date:2016-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2807T152W00000X
WA60276428152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR182842Medicaid
WA71896Medicare UPIN
OR182842Medicaid
ORU87237Medicare UPIN