NPIMap

Individual provider Active NPI

Tyler R Van Wagenen, PA

  • Physician Assistant
  • Ontario, OR
National Provider Identifier
1700656352
Registry record updated Jan 14, 2026
On this page

Key facts

NPPES NPI Registry
Primary specialty
Physician AssistantTaxonomy code 363A00000X
License
PA219187 Issued in OR
Practice address
2327 SW 4TH Ave
Ontario, OR 97914-1851
Phone
(541) 889-2340
NPI assigned
Jan 4, 2024
Last updated
Jan 14, 2026By the provider in NPPES
Sex
Male
Sole proprietor
Yes

NPPES NPI Registry

Updated by the provider on Jan 14, 2026

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Physician Assistant 363A00000X PA219187 OR Primary
Physician Assistant 363A00000X PA2766 ID

Addresses

Primary practice location

2327 SW 4TH Ave
Ontario, OR 97914-1851

Mailing address

1441 NE 10TH Ave
Payette, ID 83661-5420
Phone (208) 642-9376

Other identifiers 1

IdentifierTypeStateIssuer
500833626MedicaidOR

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in OR, ID2 enrollments
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
I20240923002998 OR Practitioner - Physician Assistant 1850832437 Reassigns benefits to 1 organization
I20250625001469 ID Practitioner - Physician Assistant 1850832437 Reassigns benefits to 1 organization

Care Compare profile

Medicare Care Compare
Specialty
Physician Assistant
Education
Other, 2023
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices
Valley Family Health Care IncGroup PAC ID 0547169591, 45 clinicians

Practice addresses (Care Compare)

2327 SW 4TH Ave
Ontario, OR 97914-1851
Phone (541) 889-2340

896 Fortner St
Ontario, OR 97914-1787
Phone (541) 881-2828

Hospital & facility affiliations

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Physician Assistant

State licenses

LicenseStateTypeSpecialty
PA2766IDMDPhysician Assistant

Practice roles

OrganizationSpecialtyStatusNew patients
Valley Family Health Care, Inc CurrentSince Jul 8, 2024 Accepting new patients
Valley Family Health Care Inc CurrentSince Apr 12, 2025 Accepting new patients
Valley Family Health Care, Inc CurrentSince Jul 8, 2024 Accepting new patients
Valley Family Health Care, Inc Past Accepting new patients
Valley Family Health Care, Inc Past Accepting new patients

Locations

207 E 12th St
Emmett, ID 83617
Phone (208) 365-1065

1441 NE 10th Ave
Payette, ID 83661
Phone (208) 642-9376

17 S 3rd St
Nyssa, OR 97913
Phone (541) 372-5738

2327 SW 4th Ave
Ontario, OR 97914
Phone (541) 889-0052

2327 SW 4th Ave
Ste 1
Ontario, OR 97914
Phone (541) 889-2340

896 Fortner St
Ontario, OR 97914
Phone (541) 709-2038

789 Washington St W
Vale, OR 97918
Phone (503) 473-2101

Interoperability endpoints

  • Direct secure messaging: tvanwagenen699560@direct.ochin.org

Organizations & group practices 5

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

Hospital & facility affiliations 5

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1704326400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1768348800000",
    "number": "1700656352",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1441 NE 10TH AVE",
            "city": "PAYETTE",
            "state": "ID",
            "postal_code": "836615420",
            "telephone_number": "208-642-9376"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2327 SW 4TH AVE",
            "city": "ONTARIO",
            "state": "OR",
            "postal_code": "979141851",
            "telephone_number": "541-889-2340"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "VAN WAGENEN",
        "first_name": "TYLER",
        "middle_name": "R",
        "name_prefix": "Mr.",
        "credential": "PA",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2024-01-04",
        "last_updated": "2026-01-14",
        "certification_date": "2026-01-14",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "OR",
            "license": "PA219187",
            "primary": true
        },
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "ID",
            "license": "PA2766",
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "500833626",
            "state": "OR"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Ontario, OR

Sources for this page

Verify at the official NPI Registry.