Provider Demographics
NPI:1215903059
Name:GAHTAN, DAVID JOSEPH (PA)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:JOSEPH
Last Name:GAHTAN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15271 SE THORNTON DR
Mailing Address - Street 2:
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97267-2552
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1919 NW LOVEJOY ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97209-1503
Practice Address - Country:US
Practice Address - Phone:509-415-5600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-23
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA01015363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORP00464824OtherRR MEDICARE
OR500603044Medicaid
ORP00464824OtherRR MEDICARE
ORR158328Medicare PIN
ORQ40518Medicare UPIN
ORR156140Medicare PIN
OR500603044Medicaid
OR131068Medicare ID - Type Unspecified
ORR156139Medicare PIN
ORR140475Medicare PIN