Healthcare Provider Details

I. General information

NPI: 1245436385
Provider Name (Legal Business Name): TANASBOURNE PEDIATRICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2007
Last Update Date: 05/12/2026
Certification Date: 05/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17895 NW EVERGREEN PKWY STE 110
BEAVERTON OR
97006-7402
US

IV. Provider business mailing address

17895 NW EVERGREEN PKWY STE 110
BEAVERTON OR
97006-7402
US

V. Phone/Fax

Practice location:
  • Phone: 503-690-8195
  • Fax: 503-629-5806
Mailing address:
  • Phone: 503-690-8195
  • Fax: 503-629-5806

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD21108
License Number StateOR

VIII. Authorized Official

Name: RAQUEL MARIE APODACA
Title or Position: OWNER
Credential:
Phone: 503-690-8195