Basic Information
| Provider Information | |||||||||
| NPI: | 1568973717 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DOUGAN | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | THOMAS | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 801 YORK ST | ||||||||
| Address2: | |||||||||
| City: | MANITOWOC | ||||||||
| State: | WI | ||||||||
| PostalCode: | 542204630 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9206639008 | ||||||||
| FaxNumber: | 9206841439 | ||||||||
| Practice Location | |||||||||
| Address1: | 303 S WALNUT ST | ||||||||
| Address2: | |||||||||
| City: | SEYMOUR | ||||||||
| State: | IN | ||||||||
| PostalCode: | 472742368 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123587705 | ||||||||
| FaxNumber: | 8882540293 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/16/2017 | ||||||||
| LastUpdateDate: | 09/16/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 10002391A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.