Provider Demographics
NPI:1295017523
Name:ROHDE, GISELE RENEE (MPAP, PA-C)
Entity Type:Individual
Prefix:
First Name:GISELE
Middle Name:RENEE
Last Name:ROHDE
Suffix:
Gender:F
Credentials:MPAP, PA-C
Other - Prefix:
Other - First Name:GISELE
Other - Middle Name:RENEE
Other - Last Name:FASSINO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
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:503-413-3900
Mailing Address - Fax:503-413-3710
Practice Address - Street 1:1040 NW 22ND AVE STE 560
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210
Practice Address - Country:US
Practice Address - Phone:503-413-5525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-13
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21635363A00000X
ORPA192781363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACB235501OtherMEDICARE ID