Healthcare Provider Details

I. General information

NPI: 1992587406
Provider Name (Legal Business Name): ETHAN GLADHILL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2023
Last Update Date: 02/07/2025
Certification Date: 02/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24988 SE STARK ST STE 220
GRESHAM OR
97030-8324
US

IV. Provider business mailing address

PO BOX 4365
PORTLAND OR
97208-4365
US

V. Phone/Fax

Practice location:
  • Phone: 503-674-1580
  • Fax: 503-674-1581
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA223756
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: