Provider Demographics
NPI:1831116862
Name:HESKETT, TAMMY ALYCE (MD)
Entity Type:Individual
Prefix:
First Name:TAMMY
Middle Name:ALYCE
Last Name:HESKETT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2801 N GANTENBEIN AVE
Mailing Address - Street 2:DEPT OF PEDIATRICS
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97227-1623
Mailing Address - Country:US
Mailing Address - Phone:503-413-2042
Mailing Address - Fax:503-413-2566
Practice Address - Street 1:2801 N GANTENBEIN AVE
Practice Address - Street 2:DEPT OF PEDIATRICS
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97227-1623
Practice Address - Country:US
Practice Address - Phone:503-413-2042
Practice Address - Fax:503-413-2566
Is Sole Proprietor?:No
Enumeration Date:2006-07-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD15616208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR065628Medicaid
OR120735Medicare ID - Type Unspecified
OR065628Medicaid