Basic Information
Provider Information | |||||||||
NPI: | 1033343298 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GUPTA | ||||||||
FirstName: | MICHELLE | ||||||||
MiddleName: | A | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | LIGHTFOOT | ||||||||
OtherFirstName: | MICHELLE | ||||||||
OtherMiddleName: | A | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MD | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 421 | ||||||||
Address2: |   | ||||||||
City: | LIBERTY LAKE | ||||||||
State: | WA | ||||||||
PostalCode: | 990190421 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8667472455 | ||||||||
FaxNumber: | 5092277070 | ||||||||
Practice Location | |||||||||
Address1: | 101 W 8TH AVE STE 100 | ||||||||
Address2: |   | ||||||||
City: | SPOKANE | ||||||||
State: | WA | ||||||||
PostalCode: | 99204 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5094745489 | ||||||||
FaxNumber: | 5092277070 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/03/2009 | ||||||||
LastUpdateDate: | 05/25/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/25/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | N/A | CA | N |   | Allopathic & Osteopathic Physicians | Urology |   | 2088P0231X | 075711 | GA | N |   | Allopathic & Osteopathic Physicians | Urology | Pediatric Urology | 2088P0231X | MD60857749 | WA | Y |   | Allopathic & Osteopathic Physicians | Urology | Pediatric Urology |
ID Information
ID | Type | State | Issuer | Description | 003177886A | 05 | GA |   | MEDICAID |