Provider Demographics
NPI:1871026286
Name:POORE, THOMAS ALEXANDER
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:ALEXANDER
Last Name:POORE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16701 SE MCGILLIVRAY BLVD STE 220
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-3462
Mailing Address - Country:US
Mailing Address - Phone:360-834-3707
Mailing Address - Fax:360-834-3569
Practice Address - Street 1:9370 SW GREENBURG RD STE 102
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97223-5428
Practice Address - Country:US
Practice Address - Phone:503-244-7894
Practice Address - Fax:503-244-7814
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-04
Last Update Date:2021-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPO61122479213E00000X
390200000X
ORDP202571213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2177764Medicaid
OR500788080Medicaid