MEDICARE: ALICE C GUNNISON PA C

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	PA159	KY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1871571356
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALICE C GUNNISON PA C

Provider Business Mailing Address
First Line	:	2406 WEST BROADWAY
Second Line	:	JENCARE NEIGHBORHOOD MEDICAL CENTER WEST BROADWAY, LLC
City	:	LOUISVILLE
State	:	KY
Zip	:	40211
Country	:	US
Telephone Number	:	502-775-1211
Fax Number	:	502-775-1221

Provider Business Practice Location Address
First Line	:	2406 WEST BROADWAY
Second Line	:	JENCARE NEIGHBORHOOD MEDICAL CENTER WEST BROADWAY, LLC
City	:	LOUISVILLE
State	:	KY
Zip	:	40211
Country	:	US
Telephone Number	:	502-775-1211
Fax Number	:	502-775-1221

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

Provider Enumeration Date	:	01/05/2006
Last Update Date	:	07/20/2015

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