Healthcare Provider Details

I. General information

NPI: 1013441997
Provider Name (Legal Business Name): THERESA M RARDIN PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/17/2017
Last Update Date: 04/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24900 SE STARK ST STE 208
GRESHAM OR
97030-3382
US

IV. Provider business mailing address

4432 NE CESAR E CHAVEZ BLVD
PORTLAND OR
97211-8232
US

V. Phone/Fax

Practice location:
  • Phone: 503-666-8149
  • Fax:
Mailing address:
  • Phone: 503-867-0019
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA182032
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: