Individual
TARA PEMBERTON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA-C
Contact information
Practice address
9495 SW LOCUST ST, SUITE A & E, PORTLAND, OR 97223-6683
(503) 505-5937
(503) 505-5922
Mailing address
9495SWLOCUST ST A, PORTLAND, OR 97223-6683
(503) 636-9011
(503) 636-3952
Taxonomy
Speciality
Code
Description
License number
State
363AM0700X
Medical Physician Assistant
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
500643737
—
OR
Enumeration date
01/05/2012
Last updated
08/20/2015
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