Basic Information
| Provider Information | |||||||||
| NPI: | 1619094174 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MICHAELMAN | ||||||||
| FirstName: | GWENDOLYN | ||||||||
| MiddleName: | BRUCH | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2727 W DR MARTIN LUTHER KING JR BLVD | ||||||||
| Address2: | SUITE NUMBER 300 | ||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336076383 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8138745707 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3001 W DR MARTIN LUTHER KING JR BLVD | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336076307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8138704000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2007 | ||||||||
| LastUpdateDate: | 06/30/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | Q62542 | CT | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AM0700X | PA9104166 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 292912100 | 05 | FL | MEDICAID |