Provider Demographics
NPI:1780157115
Name:ERICKSEN, TARA (NP)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:ERICKSEN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6944 SE STARK ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97215-2153
Mailing Address - Country:US
Mailing Address - Phone:503-997-2222
Mailing Address - Fax:
Practice Address - Street 1:4224 NE HALSEY ST STE 335
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-1568
Practice Address - Country:US
Practice Address - Phone:503-922-6616
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-08
Last Update Date:2024-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR202105081363LP0808X
CANP95010525363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CANP95010525OtherNURSE PRACTITIONER AND FURNISHING LICENSE
OR202105081OtherNURSE PRACTITIONER LICENSE