Provider Demographics
NPI:1023249125
Name:NIXON, CAROLYN KYLE
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:KYLE
Last Name:NIXON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CAROLYN
Other - Middle Name:KYLE
Other - Last Name:SIDLES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3181 SW SAM JACKSON PARK RD.
Mailing Address - Street 2:MAIL CODE SJH-2
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-3011
Mailing Address - Country:US
Mailing Address - Phone:503-494-7551
Mailing Address - Fax:503-494-4997
Practice Address - Street 1:3181 SW SAM JACKSON PARK RD.
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-3011
Practice Address - Country:US
Practice Address - Phone:503-494-7551
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-06
Last Update Date:2021-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA170105363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500679615Medicaid
OR500679615Medicaid