Provider Demographics
NPI:1164049854
Name:GAUTIER NIEVES, GLORYANNE (MD)
Entity Type:Individual
Prefix:DR
First Name:GLORYANNE
Middle Name:
Last Name:GAUTIER NIEVES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:GLORYANNE
Other - Middle Name:
Other - Last Name:GAUTIER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:5401 OLD YORK RD # KLEIN101
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19141-3030
Mailing Address - Country:US
Mailing Address - Phone:215-456-3443
Mailing Address - Fax:215-456-7602
Practice Address - Street 1:5401 OLD YORK RD # KLEIN101
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19141-3030
Practice Address - Country:US
Practice Address - Phone:215-456-3443
Practice Address - Fax:215-456-7602
Is Sole Proprietor?:No
Enumeration Date:2020-06-29
Last Update Date:2020-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT221949208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery