Healthcare Provider Details

I. General information

NPI: 1588758700
Provider Name (Legal Business Name): GRETCHEN WAYNE FAWCETT PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 04/06/2021
Certification Date: 04/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

408 S MAIN ST
LEWISTOWN IL
61542-1563
US

IV. Provider business mailing address

180 S MAIN ST
CANTON IL
61520-2608
US

V. Phone/Fax

Practice location:
  • Phone: 309-547-9700
  • Fax: 309-649-6880
Mailing address:
  • Phone: 309-647-0201
  • Fax: 309-649-5101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number85001592
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: