Provider Demographics
NPI:1801291745
Name:BOATMAN, TARA (ATC)
Entity type:Individual
Prefix:MRS
First Name:TARA
Middle Name:
Last Name:BOATMAN
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:0615 SW PALATINE HILL RD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97219-7879
Mailing Address - Country:US
Mailing Address - Phone:503-768-7551
Mailing Address - Fax:
Practice Address - Street 1:0615 SW PALATINE HILL RD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97219-7879
Practice Address - Country:US
Practice Address - Phone:503-768-7551
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-04
Last Update Date:2014-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAT-AT-101259472255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer