Provider Demographics
NPI:1679079768
Name:CLUNIES-ROSS, TANAH ELISABETH (CNM)
Entity type:Individual
Prefix:
First Name:TANAH
Middle Name:ELISABETH
Last Name:CLUNIES-ROSS
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11750 SW BARNES RD STE 300
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225-5911
Mailing Address - Country:US
Mailing Address - Phone:503-416-9940
Mailing Address - Fax:503-416-9970
Practice Address - Street 1:11750 SW BARNES RD STE 300
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-5911
Practice Address - Country:US
Practice Address - Phone:503-416-9940
Practice Address - Fax:503-416-9970
Is Sole Proprietor?:No
Enumeration Date:2018-04-05
Last Update Date:2021-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA235951367A00000X
OR201810943367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500760167Medicaid