Healthcare Provider Details

I. General information

NPI: 1497750715
Provider Name (Legal Business Name): TATYANA J DEMBROW ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2005
Last Update Date: 11/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 NE HOOD AVE SUITE 100
GRESHAM OR
97030-7303
US

IV. Provider business mailing address

3727 NE MARTIN LUTHER KING JR BLVD ATTN: CREDENTIALING
PORTLAND OR
97212-1112
US

V. Phone/Fax

Practice location:
  • Phone: 503-775-4931
  • Fax: 503-788-7285
Mailing address:
  • Phone: 503-775-4931
  • Fax: 503-788-7285

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number200850159NP FNP-PP
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier500603628
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer
# 2
Identifier9659657
Identifier TypeMEDICAID
Identifier StateWA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: