Provider Demographics
NPI:1922417724
Name:POLANCO, TARA
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:POLANCO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:227 ANDOVER ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94110-5609
Mailing Address - Country:US
Mailing Address - Phone:415-425-1026
Mailing Address - Fax:
Practice Address - Street 1:7320 SW HUNZIKER ST
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-8283
Practice Address - Country:US
Practice Address - Phone:888-317-1019
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-05
Last Update Date:2014-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1074926225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR161216796Other22 RESPIRATORY, DEVELOPMENTAL, REHABILITATIVE AND RESTORATIVE SERVICE PROVIDERS
CA22Other22 RESPIRATORY, DEVELOPMENTAL, REHABILITATIVE AND RESTORATIVE SERVICE PROVIDERS