Healthcare Provider Details

I. General information

NPI: 1447313010
Provider Name (Legal Business Name): TIARA F PACKER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/18/2006
Last Update Date: 09/24/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3620 NW SAMARITAN DRIVE SUITE 202
CORVALLIS OR
97330
US

IV. Provider business mailing address

3620 NW SAMARITAN DRIVE SUITE 202
CORVALLIS OR
97330
US

V. Phone/Fax

Practice location:
  • Phone: 541-768-4810
  • Fax:
Mailing address:
  • Phone: 541-768-4810
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number0614
License Number StateNH
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA130018
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: