Provider Demographics
NPI:1073513966
Name:GENTRY, SHARON ROSE (PAC)
Entity Type:Individual
Prefix:
First Name:SHARON
Middle Name:ROSE
Last Name:GENTRY
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1731 HEATHERDOWNS BLVD
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43614-3935
Mailing Address - Country:US
Mailing Address - Phone:740-360-2362
Mailing Address - Fax:
Practice Address - Street 1:209 W POE RD
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:OH
Practice Address - Zip Code:43402-1767
Practice Address - Country:US
Practice Address - Phone:419-936-7317
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-21
Last Update Date:2023-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH000468A363A00000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
P14827Medicare UPIN
ROPA16011Medicare ID - Type Unspecified