=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083100432
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HANNA GIETZEN PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/09/2018
-----------------------------------------------------
Last Update Date | 09/08/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 545 SE OAK ST STE F
-----------------------------------------------------
City | HILLSBORO
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97123-4147
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 971-228-8855
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 545 SE OAK ST STE F
-----------------------------------------------------
City | HILLSBORO
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97123-4147
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 971-228-8855
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | PA195530
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------