Healthcare Provider Details

I. General information

NPI: 1346227972
Provider Name (Legal Business Name): JONATHAN WILLIAM GIETZEN PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: JONATHON WILLIAM GIETZEN PA-C

II. Dates (important events)

Enumeration Date: 12/23/2005
Last Update Date: 12/30/2021
Certification Date: 12/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

SUNSET KAISER CLINIC 10060 NE EVERGREEN PARKWAY
HILLSBORO OR
97124-1196
US

IV. Provider business mailing address

1209 MOUNTAIN VIEW DR
FOREST GROVE OR
97116-3301
US

V. Phone/Fax

Practice location:
  • Phone: 503-813-2000
  • Fax:
Mailing address:
  • Phone: 503-359-4358
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA00694
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: