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General NPI Number Information
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NPI Number | 1013441997
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Entity Type | Individual
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Provider Name | THERESA M RARDIN PA
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Gender | Female
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Dates
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Enumeration Date | 04/17/2017
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Last Update Date | 04/17/2017
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Provider Practice Location Address
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Address Line | 24900 SE STARK ST STE 208
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City | GRESHAM
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State | OR
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Zip | 97030-3382
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Country | US
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Telephone | 503-666-8149
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Fax |
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Provider Business Mailing Address
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Address Line | 4432 NE CESAR E CHAVEZ BLVD
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City | PORTLAND
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State | OR
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Zip | 97211-8232
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Country | US
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Telephone | 503-867-0019
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | PA182032
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License Number State | OR
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