Healthcare Provider Details

I. General information

NPI: 1033155478
Provider Name (Legal Business Name): JEFFREY MICHAEL GANDY PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/22/2006
Last Update Date: 10/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 W WACKERLY ST SUITE 2600
MIDLAND MI
48640-4722
US

IV. Provider business mailing address

555 W WACKERLY ST SUITE 2600
MIDLAND MI
48640-4722
US

V. Phone/Fax

Practice location:
  • Phone: 989-839-8865
  • Fax: 989-631-7337
Mailing address:
  • Phone: 989-839-8865
  • Fax: 989-631-7337

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601003053
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: