Provider Demographics
NPI:1487908950
Name:GAUNTLETT, MICHELLE L (PA-C)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:L
Last Name:GAUNTLETT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:650 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:AVOCA
Mailing Address - State:PA
Mailing Address - Zip Code:18641-1518
Mailing Address - Country:US
Mailing Address - Phone:570-471-3352
Mailing Address - Fax:570-471-7873
Practice Address - Street 1:821 S MAIN ST
Practice Address - Street 2:SUITE3
Practice Address - City:OLD FORGE
Practice Address - State:PA
Practice Address - Zip Code:18518-1497
Practice Address - Country:US
Practice Address - Phone:570-457-0562
Practice Address - Fax:570-457-0603
Is Sole Proprietor?:No
Enumeration Date:2012-11-05
Last Update Date:2022-01-07
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
PAOA001000363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA086242ROKMedicare Oscar/Certification