NPIMap

Individual provider Active NPI

Garrett Wilson, PA

  • Physician Assistant
  • Portland, OR
National Provider Identifier
1649716267
Registry record updated Mar 25, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Physician AssistantTaxonomy code 363A00000X
License
PA180901 Issued in OR
Practice address
4805 NE Glisan St Ste 11N
Portland, OR 97213-2933
Phone
(503) 215-2300
NPI assigned
Jan 7, 2017
Last updated
Mar 25, 2021By the provider in NPPES
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Mar 25, 2021

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Physician Assistant 363A00000X PA180901 OR Primary

Addresses

Primary practice location

4805 NE Glisan St Ste 11N
Portland, OR 97213-2933

Mailing address

PO Box 3158
Portland, OR 97208-3158

Other identifiers 1

IdentifierTypeStateIssuer
500731071MedicaidOR

Electronic endpoints 1

TypeEndpointUseAffiliation
Direct Messaging Address gwilson243940@oc.providencedirect.org

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in OR
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20170706001110 OR Practitioner - Physician Assistant 2264701200 Reassigns benefits to 3 organizations

Care Compare profile

Medicare Care Compare
Specialty
Physician Assistant
Education
Other, 2016
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices

Practice addresses (Care Compare)

10330 SE 32ND Ave
Milwaukie, OR 97222-6594

1321 NE 99TH Ave
Suite 200
Portland, OR 97220-9439
Phone (503) 215-4250

4805 NE Glisan St
Portland, OR 97213-2933

9135 SW Barnes Rd
Suite 261
Portland, OR 97225-6784
Phone (503) 216-6300

9205 SW Barnes Rd
Portland, OR 97225-6603

Hospital & facility affiliations

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Physician Assistant

Practice roles

OrganizationSpecialtyStatusNew patients
Providence Health & Services Oregon CurrentSince Jul 10, 2017 Accepting new patients
Providence Health & Services - Oregon CurrentSince Jul 10, 2017 Accepting new patients
Providence Health & Services - Oregon CurrentSince Jul 10, 2017 Accepting new patients
Providence Health & Services Oregon CurrentSince Jul 10, 2017 Accepting new patients

Locations

10330 SE 32nd Ave
Ste 205
Portland, OR 97222
Phone (503) 513-8950

1321 NE 99th Ave
Ste 200
Portland, OR 97220
Phone (503) 215-4250

4805 NE Glisan St
Portland, OR 97213
Phone (503) 215-1111

4805 NE Glisan St
Ste 11N
Portland, OR 97213
Phone (503) 215-1350

5050 NE Hoyt St
Ste 240
Portland, OR 97213
Phone (503) 215-6480

9205 SW Barnes Rd
Portland, OR 97225
Phone (503) 216-1234

Organizations & group practices 7

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

Hospital & facility affiliations 6

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1483747200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1616630400000",
    "number": "1649716267",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 3158",
            "city": "PORTLAND",
            "state": "OR",
            "postal_code": "972083158"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4805 NE GLISAN ST STE 11N",
            "city": "PORTLAND",
            "state": "OR",
            "postal_code": "972132933",
            "telephone_number": "503-215-2300"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WILSON",
        "first_name": "GARRETT",
        "credential": "PA",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2017-01-07",
        "last_updated": "2021-03-25",
        "certification_date": "2021-03-25",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "OR",
            "license": "PA180901",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "500731071",
            "state": "OR"
        }
    ],
    "endpoints": [
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "gwilson243940@oc.providencedirect.org",
            "affiliation": "N",
            "address_1": "4805 NE Glisan St Ste 11N",
            "city": "Portland",
            "state": "OR",
            "country_code": "US",
            "postal_code": "972132933",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

Other providers in Portland, OR

Sources for this page

Verify at the official NPI Registry.