Basic Information
| Provider Information | |||||||||
| NPI: | 1689991804 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TOMCZAK | ||||||||
| FirstName: | CASSANDRA | ||||||||
| MiddleName: | BREE | ||||||||
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| Credential: | DPM | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3777 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972083777 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034133900 | ||||||||
| FaxNumber: | 5034133710 | ||||||||
| Practice Location | |||||||||
| Address1: | 19250 SW 65TH AVE STE 200 | ||||||||
| Address2: | |||||||||
| City: | TUALATIN | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97062 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034132005 | ||||||||
| FaxNumber: | 5034133699 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/27/2010 | ||||||||
| LastUpdateDate: | 12/03/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | DP164497 | OR | N | Podiatric Medicine & Surgery Service Providers | Podiatrist | 213ES0103X | DP164497 | OR | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
No ID Information.