Healthcare Provider Details

I. General information

NPI: 1013365469
Provider Name (Legal Business Name): JOSHUA GIETZEN PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2016
Last Update Date: 11/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1151 N ADAIR ST
CORNELIUS OR
97113-8900
US

IV. Provider business mailing address

PO BOX 6149
BEAVERTON OR
97007-0149
US

V. Phone/Fax

Practice location:
  • Phone: 503-359-5564
  • Fax: 503-357-4371
Mailing address:
  • Phone: 503-352-8657
  • Fax: 503-352-8658

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA184309
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: