Provider Demographics
NPI:1255318952
Name:TABOR, MARK (PA-C)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:TABOR
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 96
Mailing Address - Street 2:
Mailing Address - City:BORING
Mailing Address - State:OR
Mailing Address - Zip Code:97009-0096
Mailing Address - Country:US
Mailing Address - Phone:503-325-0333
Mailing Address - Fax:
Practice Address - Street 1:2120 EXCHANGE ST
Practice Address - Street 2:SUITE 111
Practice Address - City:ASTORIA
Practice Address - State:OR
Practice Address - Zip Code:97103-3365
Practice Address - Country:US
Practice Address - Phone:503-325-0333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-23
Last Update Date:2016-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA00726363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR840126019OtherREGENCE BS/BC
ORP00087890OtherRR MC
OR218105Medicaid
WA8441354Medicaid
383993Medicare Oscar/Certification
WA8441354Medicaid
ORP00087890OtherRR MC