Provider Demographics
NPI:1033155478
Name:GANDY, JEFFREY MICHAEL (PA-C)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:MICHAEL
Last Name:GANDY
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 1:555 W WACKERLY ST
Mailing Address - Street 2:SUITE 2600
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48640-4722
Mailing Address - Country:US
Mailing Address - Phone:989-839-8865
Mailing Address - Fax:989-631-7337
Practice Address - Street 1:555 W WACKERLY ST
Practice Address - Street 2:SUITE 2600
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48640-4722
Practice Address - Country:US
Practice Address - Phone:989-839-8865
Practice Address - Fax:989-631-7337
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-22
Last Update Date:2011-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601003053363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P43710Medicare PIN