Healthcare Provider Details

I. General information

NPI: 1346799632
Provider Name (Legal Business Name): TYRELL JAGELSKI PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2016
Last Update Date: 10/20/2020
Certification Date: 10/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1003 PROVIDENCE DR STE 110
NEWBERG OR
97132-7521
US

IV. Provider business mailing address

PO BOX 3158
PORTLAND OR
97208-3158
US

V. Phone/Fax

Practice location:
  • Phone: 503-537-5900
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA190255
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: