Provider Demographics
NPI:1033146980
Name:BLOEM, CARLA (PA-C)
Entity Type:Individual
Prefix:MS
First Name:CARLA
Middle Name:
Last Name:BLOEM
Suffix:
Gender:F
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 1:221 W STEWART AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97501-3609
Mailing Address - Country:US
Mailing Address - Phone:541-776-2003
Mailing Address - Fax:541-776-9833
Practice Address - Street 1:221 W STEWART AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97501-3609
Practice Address - Country:US
Practice Address - Phone:541-776-2003
Practice Address - Fax:541-776-9833
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2015-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA160148363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WYS69950Medicare UPIN