Healthcare Provider Details

I. General information

NPI: 1417433145
Provider Name (Legal Business Name): CAROLINA ALEXANDRA VAN TULDER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2018
Last Update Date: 04/15/2025
Certification Date: 04/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10215 SW HALL BLVD
TIGARD OR
97223-8809
US

IV. Provider business mailing address

10215 SW HALL BLVD
TIGARD OR
97223-8809
US

V. Phone/Fax

Practice location:
  • Phone: 503-245-2415
  • Fax: 503-244-5963
Mailing address:
  • Phone: 503-245-2415
  • Fax: 503-244-5963

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA214771
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: