Healthcare Provider Details

I. General information

NPI: 1902975055
Provider Name (Legal Business Name): ELISABETH LUISE GAMMELIN PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2006
Last Update Date: 06/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 LAKE STATION LAKE CLINIC
YELLOWSTONE NATIONAL PARK WY
82190
US

IV. Provider business mailing address

283 N 1ST E
DRIGGS ID
83422-5109
US

V. Phone/Fax

Practice location:
  • Phone: 307-242-7241
  • Fax: 307-242-7273
Mailing address:
  • Phone: 208-354-2302
  • Fax: 208-354-8392

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA-448
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: