Basic Information
Provider Information
NPI: 1003139395
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: SHINHAM
FirstName: MICHELLE
MiddleName: GIBSON
NamePrefix:  
NameSuffix:  
Credential: PA-C
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName: GIBSON
OtherFirstName: MICHELLE
OtherMiddleName: DENISE
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType: 1
Mailing Information
Address1: 4600 SW 46TH CT
Address2: SUITE 150
City: OCALA
State: FL
PostalCode: 344745708
CountryCode: US
TelephoneNumber: 3523695999
FaxNumber: 3526294227
Practice Location
Address1: 4600 SW 46TH CT
Address2: SUITE 150
City: OCALA
State: FL
PostalCode: 344745708
CountryCode: US
TelephoneNumber: 3523695999
FaxNumber: 3526294227
Other Information
ProviderEnumerationDate: 03/01/2010
LastUpdateDate: 03/01/2010
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
363A00000X9105348FLY Physician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant 

No ID Information.


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