Healthcare Provider Details

I. General information

NPI: 1629635008
Provider Name (Legal Business Name): CARLY JANE KING GRAVEL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CARLY JANE KING PA

II. Dates (important events)

Enumeration Date: 05/21/2019
Last Update Date: 09/18/2025
Certification Date: 09/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3303 S BOND AVE
PORTLAND OR
97239-4501
US

IV. Provider business mailing address

1400 SW 5TH AVE STE 500
PORTLAND OR
97201-5537
US

V. Phone/Fax

Practice location:
  • Phone: 503-494-6594
  • Fax: 503-494-5385
Mailing address:
  • Phone: 866-617-6855
  • Fax: 503-346-8015

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number58259
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA207931
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: