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NPI Code Detail

MEDICARE: MS. THEA N CLOUSE-GAWRONSKI PA-C

MEDICARE: MS. THEA N CLOUSE-GAWRONSKI PA-C
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1363A00000XPhysician Assistant5601004262MI

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
15411258OTHERMIBCBS PIN

General Provider Information

NPI Number : 1063537819
Entity Type Code : Individual
Provider Name (Legal Business Name) : MS. THEA N CLOUSE-GAWRONSKI PA-C
Provider Business Mailing Address
First Line : 1150 E SHERMAN BLVD STE 2400
Second Line :
City : MUSKEGON
State : MI
Zip : 49444-1886
Country : US
Telephone Number : 231-672-4243
Fax Number : 231-727-4217
Provider Business Practice Location Address
First Line : 1150 E SHERMAN BLVD STE 2400
Second Line :
City : MUSKEGON
State : MI
Zip : 49444-1886
Country : US
Telephone Number : 231-672-4243
Fax Number : 231-727-4217
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 03/20/2007
Last Update Date : 10/16/2023

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Directions to “ MS. THEA N CLOUSE-GAWRONSKI PA-C” Practice Location

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