Healthcare Provider Details

I. General information

NPI: 1568973717
Provider Name (Legal Business Name): GREGORY THOMAS DOUGAN PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/16/2017
Last Update Date: 11/12/2025
Certification Date: 11/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

303 S WALNUT ST
SEYMOUR IN
47274-2368
US

IV. Provider business mailing address

801 YORK ST
MANITOWOC WI
54220-4630
US

V. Phone/Fax

Practice location:
  • Phone: 812-358-7705
  • Fax: 888-254-0293
Mailing address:
  • Phone: 920-663-9008
  • Fax: 920-684-1439

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10002391A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: