Provider Demographics
NPI:1962269332
Name:TIEDE, TRAVIS R (APRN)
Entity type:Individual
Prefix:
First Name:TRAVIS
Middle Name:R
Last Name:TIEDE
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11827 SE WHITE TAIL DR
Mailing Address - Street 2:
Mailing Address - City:HAPPY VALLEY
Mailing Address - State:OR
Mailing Address - Zip Code:97086-4722
Mailing Address - Country:US
Mailing Address - Phone:612-703-5277
Mailing Address - Fax:
Practice Address - Street 1:12360 SE SUNNYSIDE RD
Practice Address - Street 2:
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015-9320
Practice Address - Country:US
Practice Address - Phone:503-303-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-04
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10016365363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health