Basic Information
| Provider Information | |||||||||
| NPI: | 1528563160 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TARASCO | ||||||||
| FirstName: | ALEXANDER | ||||||||
| MiddleName: | MARIO | ||||||||
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| Credential: | ND | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | TARASCO | ||||||||
| OtherFirstName: | MARIO | ||||||||
| OtherMiddleName: | |||||||||
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| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3660 SE 29TH AVE APT 2211 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972022179 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5039849188 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 9775 SE SUNNYSIDE RD STE 200 | ||||||||
| Address2: | |||||||||
| City: | CLACKAMAS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970155721 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036558471 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2018 | ||||||||
| LastUpdateDate: | 12/22/2020 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/22/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 175F00000X | OR | Y | Other Service Providers | Naturopath |
No ID Information.