=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831285832
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GRETCHEN L GAEBEL PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/05/2006
-----------------------------------------------------
Last Update Date | 10/20/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3511 SE WILLOUGHBY BLVD
-----------------------------------------------------
City | STUART
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34994-5059
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-221-7789
-----------------------------------------------------
Fax | 772-221-8584
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 681 SW WOODSIDE CT
-----------------------------------------------------
City | PALM CITY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34990-4337
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-631-5873
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | PA9101775
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------