Provider Demographics
NPI:1245436385
Name:TANASBOURNE PEDIATRICS, LLC
Entity type:Organization
Organization Name:TANASBOURNE PEDIATRICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:RAQUEL
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:APODACA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:503-690-8195
Mailing Address - Street 1:1881 NW 185TH AVE
Mailing Address - Street 2:SUITE 207
Mailing Address - City:ALOHA
Mailing Address - State:OR
Mailing Address - Zip Code:97006-6822
Mailing Address - Country:US
Mailing Address - Phone:503-690-8195
Mailing Address - Fax:503-629-5806
Practice Address - Street 1:1881 NW 185TH AVE
Practice Address - Street 2:SUITE 207
Practice Address - City:ALOHA
Practice Address - State:OR
Practice Address - Zip Code:97006-6822
Practice Address - Country:US
Practice Address - Phone:503-690-8195
Practice Address - Fax:503-629-5806
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD21108208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
G74404Medicare UPIN
G99523Medicare UPIN