MEDICARE: MALLORY GAUTHIER PHYSICIAN ASSISTANT

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	363A00000X	Physician Assistant	085006422	IL

General Provider Information

NPI Number	:	1598277907
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MALLORY GAUTHIER PHYSICIAN ASSISTANT

Provider Business Mailing Address
First Line	:	207 W JACKSON ST STE 201
Second Line	:
City	:	CARBONDALE
State	:	IL
Zip	:	62901-1408
Country	:	US
Telephone Number	:	618-457-2963
Fax Number	:	618-457-2992

Provider Business Practice Location Address
First Line	:	207 W JACKSON ST STE 201
Second Line	:
City	:	CARBONDALE
State	:	IL
Zip	:	62901-1408
Country	:	US
Telephone Number	:	618-457-2963
Fax Number	:	618-457-2992

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

Provider Enumeration Date	:	10/26/2017
Last Update Date	:	04/20/2026

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