Provider Demographics
NPI:1770310401
Name:COSTIGAN, TABITHA ROCHELLE
Entity type:Individual
Prefix:
First Name:TABITHA
Middle Name:ROCHELLE
Last Name:COSTIGAN
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 1:22 SE 11TH AVE APT 512
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-1393
Mailing Address - Country:US
Mailing Address - Phone:503-888-1012
Mailing Address - Fax:
Practice Address - Street 1:1421 SE ANKENY ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-1471
Practice Address - Country:US
Practice Address - Phone:503-284-7996
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-17
Last Update Date:2024-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist