Provider Demographics
NPI:1447313010
Name:PACKER, TIARA F (PA-C)
Entity type:Individual
Prefix:
First Name:TIARA
Middle Name:F
Last Name:PACKER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3620 NW SAMARITAN DRIVE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97330
Mailing Address - Country:US
Mailing Address - Phone:541-768-4810
Mailing Address - Fax:
Practice Address - Street 1:3620 NW SAMARITAN DRIVE
Practice Address - Street 2:SUITE 202
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330
Practice Address - Country:US
Practice Address - Phone:541-768-4810
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2010-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH0614363AS0400X
ORPA130018363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH01Y005045NH03OtherANTHEM BCBS MOA
NH30334821Medicaid
NH01Y005045NH02OtherANTHEM BCBS MCH
NHAP2779Medicare PIN