Healthcare Provider Details

I. General information

NPI: 1871498055
Provider Name (Legal Business Name): SHAMARU TINIYA SITAR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/08/2026
Last Update Date: 10/08/2026
Certification Date: 10/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

913 SW 16TH AVE
PORTLAND OR
97205-1730
US

IV. Provider business mailing address

1408 SE BOISE ST APT 8
PORTLAND OR
97202-3900
US

V. Phone/Fax

Practice location:
  • Phone: 503-228-5000
  • Fax:
Mailing address:
  • Phone: 503-228-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number28050
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: