MEDICARE: JOHNENE ANN GASTON BC-HIS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	237700000X	Hearing Instrument Specialist	3208	MI

General Provider Information

NPI Number	:	1457859787
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHNENE ANN GASTON BC-HIS

Provider Business Mailing Address
First Line	:	2266 SPRINGPORT RD UNIT D
Second Line	:
City	:	JACKSON
State	:	MI
Zip	:	49202-1454
Country	:	US
Telephone Number	:	517-788-8000
Fax Number	:	517-788-3898

Provider Business Practice Location Address
First Line	:	2266 SPRINGPORT RD UNIT D
Second Line	:
City	:	JACKSON
State	:	MI
Zip	:	49202-1454
Country	:	US
Telephone Number	:	517-788-8000
Fax Number	:	517-788-3898

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/01/2018
Last Update Date	:	02/01/2018

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