MEDICARE: TARA KENNY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program
2	207P00000X	Emergency Medicine Physician	M-14731	ID

General Provider Information

NPI Number	:	1477916310
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TARA KENNY

Provider Business Mailing Address
First Line	:	3181 SW SAM JACKSON PARK RD
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97239-3011
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3080 E GENTRY WAY STE 210
Second Line	:
City	:	MERIDIAN
State	:	ID
Zip	:	83642-3013
Country	:	US
Telephone Number	:	208-810-2309
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/29/2016
Last Update Date	:	06/20/2019

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Directions to “ TARA KENNY ” Practice Location

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