Provider Demographics
NPI:1982067450
Name:OETKEN, TARA (MD)
Entity Type:Individual
Prefix:DR
First Name:TARA
Middle Name:
Last Name:OETKEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MRS
Other - First Name:TARA
Other - Middle Name:
Other - Last Name:OETKEN MCMAHON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1703 S MERIDIAN STE 101
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98371-7590
Mailing Address - Country:US
Mailing Address - Phone:253-848-3000
Mailing Address - Fax:253-840-6514
Practice Address - Street 1:1905 W COLLEGE ST
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59718-4061
Practice Address - Country:US
Practice Address - Phone:406-587-4432
Practice Address - Fax:406-587-7015
Is Sole Proprietor?:No
Enumeration Date:2016-04-01
Last Update Date:2024-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT132241207N00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty