1215332986 NPI number — MRS. JAMIE ELISE GONZALES PA-C

Table of content: MRS. JAMIE ELISE GONZALES PA-C (NPI 1215332986)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215332986 NPI number — MRS. JAMIE ELISE GONZALES PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GONZALES
Provider First Name:
JAMIE
Provider Middle Name:
ELISE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
TROUPE
Provider Other First Name:
JAMIE
Provider Other Middle Name:
ELISE
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA-C
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1215332986
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/23/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
112 AIRPORT BUSINESS PARK DR
Provider Second Line Business Mailing Address:
STE H
Provider Business Mailing Address City Name:
SHELBYVILLE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37160-7452
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
931-680-6360
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
112 AIRPORT BUSINESS PARK DR
Provider Second Line Business Practice Location Address:
STE H
Provider Business Practice Location Address City Name:
SHELBYVILLE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37160-7452
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
931-680-6360
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/23/2014

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: 363AM0700X , with the licence number:  2652 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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