Basic Information
| Provider Information | |||||||||
| NPI: | 1346227972 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GIETZEN | ||||||||
| FirstName: | JONATHAN | ||||||||
| MiddleName: | WILLIAM | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GIETZEN | ||||||||
| OtherFirstName: | JONATHON | ||||||||
| OtherMiddleName: | WILLIAM | ||||||||
| OtherNamePrefix: | MR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA-C | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1209 MOUNTAIN VIEW DR | ||||||||
| Address2: | |||||||||
| City: | FOREST GROVE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 971163301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033594358 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | SUNSET KAISER CLINIC | ||||||||
| Address2: | 10060 NE EVERGREEN PARKWAY | ||||||||
| City: | HILLSBORO | ||||||||
| State: | OR | ||||||||
| PostalCode: | 971241196 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5038132000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/23/2005 | ||||||||
| LastUpdateDate: | 12/30/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA00694 | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.