1902975055 NPI number — ELISABETH LUISE GAMMELIN PA

Table of content: ELISABETH LUISE GAMMELIN PA (NPI 1902975055)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902975055 NPI number — ELISABETH LUISE GAMMELIN PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GAMMELIN
Provider First Name:
ELISABETH
Provider Middle Name:
LUISE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1902975055
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/02/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
283 N 1ST E
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DRIGGS
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83422-5109
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-354-2302
Provider Business Mailing Address Fax Number:
208-354-8392

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1 LAKE STATION
Provider Second Line Business Practice Location Address:
LAKE CLINIC
Provider Business Practice Location Address City Name:
YELLOWSTONE NATIONAL PARK
Provider Business Practice Location Address State Name:
WY
Provider Business Practice Location Address Postal Code:
82190
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
307-242-7241
Provider Business Practice Location Address Fax Number:
307-242-7273
Provider Enumeration Date:
11/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  PA-448 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 806724500 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".




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