Provider Demographics
NPI:1558651158
Name:FIELDEN, GARY TAYLOR (PA)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:TAYLOR
Last Name:FIELDEN
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 1:541 NE 20TH AVE STE 225
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-2895
Mailing Address - Country:US
Mailing Address - Phone:503-963-2801
Mailing Address - Fax:503-963-2825
Practice Address - Street 1:5050 NE HOYT ST STE 340
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-2983
Practice Address - Country:US
Practice Address - Phone:503-234-9861
Practice Address - Fax:503-238-0873
Is Sole Proprietor?:No
Enumeration Date:2011-04-15
Last Update Date:2023-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA1723210363A00000X
ORPA172310363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2232211Medicaid
OR500685927Medicaid
TN103I972997Medicare PIN
TN0677340001Medicare NSC
TN0677340003Medicare NSC
TN1523597Medicaid