Basic Information
| Provider Information | |||||||||
| NPI: | 1588321038 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TUMINARO | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3158 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972083158 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417327950 | ||||||||
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| Practice Location | |||||||||
| Address1: | 965 ELLENDALE DR | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975048215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417326000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/19/2021 | ||||||||
| LastUpdateDate: | 06/22/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/22/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA208211 | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.