Provider Demographics
NPI:1033145172
Name:GAUTHIER, LEON (PA-C)
Entity Type:Individual
Prefix:MR
First Name:LEON
Middle Name:
Last Name:GAUTHIER
Suffix:
Gender:M
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 1:220 N PARK AVE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:HERRIN
Mailing Address - State:IL
Mailing Address - Zip Code:62948-3150
Mailing Address - Country:US
Mailing Address - Phone:618-942-3344
Mailing Address - Fax:618-942-5045
Practice Address - Street 1:220 N PARK AVE
Practice Address - Street 2:SUITE 2
Practice Address - City:HERRIN
Practice Address - State:IL
Practice Address - Zip Code:62948-3150
Practice Address - Country:US
Practice Address - Phone:618-942-3344
Practice Address - Fax:618-942-5045
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085000934363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL371359450OtherFEDERAL EMPLOYER ID NUMBE
IL441379OtherHEALTHLINK HMO/PPO PROV #
ILCB3700OtherRAILROAD MEDICARE GROUP
ILL84852OtherUMWA PROVIDER NUMBER
IL970023073OtherRAILROAD PROVIDER NUMBER
ILCB3700OtherRAILROAD MEDICARE GROUP
IL371359450OtherFEDERAL EMPLOYER ID NUMBE
ILS44553Medicare UPIN