Provider Demographics
NPI:1114779550
Name:GIENTKE, ALEXANDRIA (AGNP)
Entity type:Individual
Prefix:
First Name:ALEXANDRIA
Middle Name:
Last Name:GIENTKE
Suffix:
Gender:F
Credentials:AGNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1821 NE BOBBIE CT
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-6609
Mailing Address - Country:US
Mailing Address - Phone:503-568-6545
Mailing Address - Fax:
Practice Address - Street 1:1345 NW WALL ST STE 302
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97703-1970
Practice Address - Country:US
Practice Address - Phone:541-323-3960
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-01
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10024114207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine