Healthcare Provider Details

I. General information

NPI: 1285476630
Provider Name (Legal Business Name): GRACE TUDOR PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2024
Last Update Date: 05/13/2026
Certification Date: 05/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24076 SE STARK ST STE 110
GRESHAM OR
97030-3374
US

IV. Provider business mailing address

24076 SE STARK ST STE 110
GRESHAM OR
97030-3374
US

V. Phone/Fax

Practice location:
  • Phone: 503-661-5388
  • Fax: 503-666-9393
Mailing address:
  • Phone: 503-661-5388
  • Fax: 503-666-9393

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA227904
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: