Provider Demographics
NPI:1265572937
Name:FOULKE, TIM CHARLES (PMHNP)
Entity type:Individual
Prefix:
First Name:TIM
Middle Name:CHARLES
Last Name:FOULKE
Suffix:
Gender:M
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2434 NE 36TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97212-5241
Mailing Address - Country:US
Mailing Address - Phone:503-284-8372
Mailing Address - Fax:
Practice Address - Street 1:2015 NE 39TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97212-5305
Practice Address - Country:US
Practice Address - Phone:503-422-3253
Practice Address - Fax:503-281-0052
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR080045508N6363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORS52783Medicare UPIN