Provider Demographics
NPI:1417433145
Name:VAN TULDER, CAROLINA ALEXANDRA (PA-C)
Entity type:Individual
Prefix:
First Name:CAROLINA
Middle Name:ALEXANDRA
Last Name:VAN TULDER
Suffix:
Gender:
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10215 SW HALL BLVD
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223-8809
Mailing Address - Country:US
Mailing Address - Phone:503-245-2415
Mailing Address - Fax:503-244-5963
Practice Address - Street 1:10215 SW HALL BLVD
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-8809
Practice Address - Country:US
Practice Address - Phone:503-245-2415
Practice Address - Fax:503-244-5963
Is Sole Proprietor?:No
Enumeration Date:2018-07-16
Last Update Date:2025-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA214771363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0010-08076OtherMEDICAL LICENSE