Healthcare Provider Details

I. General information

NPI: 1134420656
Provider Name (Legal Business Name): JONATHAN RICHARD TARDIFF PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2010
Last Update Date: 10/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2935 SW CEDAR HILLS BLVD
BEAVERTON OR
97005-1342
US

IV. Provider business mailing address

PO BOX 568
CORNELIUS OR
97113-0568
US

V. Phone/Fax

Practice location:
  • Phone: 503-352-6000
  • Fax:
Mailing address:
  • Phone: 503-352-8657
  • Fax: 503-352-8658

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: