Provider Demographics
NPI:1003239500
Name:O'CALLAGHAN, GINA MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:MARIE
Last Name:O'CALLAGHAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2180 HENRY TECKLENBURG DR
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29414-5798
Mailing Address - Country:US
Mailing Address - Phone:843-556-8886
Mailing Address - Fax:
Practice Address - Street 1:3000 OLD CENTRE RD
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-4883
Practice Address - Country:US
Practice Address - Phone:269-321-7546
Practice Address - Fax:269-321-1705
Is Sole Proprietor?:No
Enumeration Date:2014-02-04
Last Update Date:2020-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2108363A00000X
MI5601006884363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant