Provider Demographics
NPI:1013441997
Name:RARDIN, THERESA M (PA)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:M
Last Name:RARDIN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4432 NE CESAR E CHAVEZ BLVD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97211-8232
Mailing Address - Country:US
Mailing Address - Phone:503-867-0019
Mailing Address - Fax:
Practice Address - Street 1:24900 SE STARK ST STE 208
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-3382
Practice Address - Country:US
Practice Address - Phone:503-666-8149
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-17
Last Update Date:2017-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA182032363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant