1295017523 NPI number — GISELE RENEE ROHDE MPAP, PA-C

Table of content: GISELE RENEE ROHDE MPAP, PA-C (NPI 1295017523)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295017523 NPI number — GISELE RENEE ROHDE MPAP, PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROHDE
Provider First Name:
GISELE
Provider Middle Name:
RENEE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MPAP, PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
FASSINO
Provider Other First Name:
GISELE
Provider Other Middle Name:
RENEE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA-C
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1295017523
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/28/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3777
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97208-3777
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-413-3900
Provider Business Mailing Address Fax Number:
503-413-3710

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1040 NW 22ND AVE STE 560
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97210
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-413-5525
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/13/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  21635 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: PA192781 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: CB235501 . This is a "MEDICARE ID" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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