MEDICARE: DIANA MARIE TATSUMI PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	50.007166RX	OH

General Provider Information

NPI Number	:	1932720992
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DIANA MARIE TATSUMI PA-C

Provider Business Mailing Address
First Line	:	2730 SW MOODY AVE
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97201-5042
Country	:	US
Telephone Number	:	503-494-3633
Fax Number	:

Provider Business Practice Location Address
First Line	:	3805 EDWARDS RD STE 450
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45209-1948
Country	:	US
Telephone Number	:	503-494-3633
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/30/2020
Last Update Date	:	11/16/2023

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