Basic Information
Provider Information | |||||||||
NPI: | 1336430305 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HAMAN | ||||||||
FirstName: | TARA | ||||||||
MiddleName: | EILEEN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | NNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 4105 | ||||||||
Address2: |   | ||||||||
City: | PORTLAND | ||||||||
State: | OR | ||||||||
PostalCode: | 972084105 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8669071068 | ||||||||
FaxNumber: | 4259179141 | ||||||||
Practice Location | |||||||||
Address1: | 3200 PROVIDENCE DR | ||||||||
Address2: |   | ||||||||
City: | ANCHORAGE | ||||||||
State: | AK | ||||||||
PostalCode: | 995084615 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9072125006 | ||||||||
FaxNumber: | 9072124896 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/26/2011 | ||||||||
LastUpdateDate: | 10/29/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | R168345-5 | MN | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   | 363LN0005X | R 168345-5 | MN | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Neonatal, Critical Care | 363LN0000X | 104039 | AK | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Neonatal |
ID Information
ID | Type | State | Issuer | Description | ENROLLED | 05 | IA |   | MEDICAID | ENROLLED | 05 | MN |   | MEDICAID |