Healthcare Provider Details

I. General information

NPI: 1114541745
Provider Name (Legal Business Name): TAMARA GEDROSE RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/29/2020
Last Update Date: 05/29/2020
Certification Date: 05/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1150 N ROOSEVELT DR APT 104
SEASIDE OR
97138-7053
US

IV. Provider business mailing address

4400 NE HALSEY ST STE 200
PORTLAND OR
97213-1545
US

V. Phone/Fax

Practice location:
  • Phone: 503-717-7150
  • Fax:
Mailing address:
  • Phone: 503-215-6556
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number201042536RN
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: