Healthcare Provider Details

I. General information

NPI: 1710226204
Provider Name (Legal Business Name): TARA RAE THOMPSON APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/04/2013
Last Update Date: 03/12/2024
Certification Date: 03/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1698 E MCANDREWS RD STE 400
MEDFORD OR
97504-5590
US

IV. Provider business mailing address

1698 E MCANDREWS RD STE 400
MEDFORD OR
97504-5590
US

V. Phone/Fax

Practice location:
  • Phone: 541-732-7400
  • Fax: 541-732-3410
Mailing address:
  • Phone: 541-732-7400
  • Fax: 541-732-3410

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License NumberAP 07195
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License NumberAP61501809
License Number StateWA
# 3
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number10018842APRN-NP
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: