Healthcare Provider Details

I. General information

NPI: 1508951864
Provider Name (Legal Business Name): TINA MARINA PASSALARIS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 03/16/2021
Certification Date: 03/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 NW ELKS DR STE 100
CORVALLIS OR
97330-3757
US

IV. Provider business mailing address

PO BOX 1189
CORVALLIS OR
97339-1189
US

V. Phone/Fax

Practice location:
  • Phone: 541-768-4950
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License NumberMD00032741
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License NumberMD179486
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: