Healthcare Provider Details

I. General information

NPI: 1598277907
Provider Name (Legal Business Name): MALLORY GAUTHIER PHYSICIAN ASSISTANT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2017
Last Update Date: 08/28/2025
Certification Date: 08/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

207 W JACKSON ST STE 201
CARBONDALE IL
62901-1408
US

IV. Provider business mailing address

207 W JACKSON ST STE 201
CARBONDALE IL
62901-1408
US

V. Phone/Fax

Practice location:
  • Phone: 618-457-2963
  • Fax: 618-457-2992
Mailing address:
  • Phone: 618-457-2963
  • Fax: 618-457-2992

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085006422
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: