Provider Demographics
NPI:1992798060
Name:VAN HORN, JONATHAN REUEL (PAC)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:REUEL
Last Name:VAN HORN
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3777
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3777
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:300 N GRAHAM ST STE 125
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97227-1683
Practice Address - Country:US
Practice Address - Phone:503-413-3714
Practice Address - Fax:503-413-2061
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2019-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA00833363AS0400X, 363A00000X
WAPA10004741363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500600859Medicaid
ORP62816Medicare UPIN