Individual
MR. TYLER R VAN WAGENEN
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
PA
Contact information
Practice address
2327 SW 4TH AVE, ONTARIO, OR 97914-1851
(541) 889-2340
Mailing address
1441 NE 10TH AVE, PAYETTE, ID 83661-5420
(208) 642-9376
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
PA219187
OR
363A00000X
Physician Assistant
PA2766
ID
363A00000X
Physician Assistant
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
500833626
—
OR
Enumeration date
01/04/2024
Last updated
01/14/2026
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