Healthcare Provider Details

I. General information

NPI: 1659891414
Provider Name (Legal Business Name): ANDREW JAMES TEMBROCK CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2017
Last Update Date: 06/22/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3181 SW SAM JACKSON PARK RD
PORTLAND OR
97239-3011
US

IV. Provider business mailing address

201 W NEWTON ST APT 4
BOSTON MA
02116-5841
US

V. Phone/Fax

Practice location:
  • Phone: 503-494-8311
  • Fax:
Mailing address:
  • Phone: 218-310-6764
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number115237
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: