Provider Demographics
NPI:1245412204
Name:GRIES, AUDREY K (PAC)
Entity Type:Individual
Prefix:MRS
First Name:AUDREY
Middle Name:K
Last Name:GRIES
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:MS
Other - First Name:AUDREY
Other - Middle Name:K
Other - Last Name:BRESTEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:301 E HILLCREST AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANOLA
Mailing Address - State:IA
Mailing Address - Zip Code:50125-9027
Mailing Address - Country:US
Mailing Address - Phone:515-961-3700
Mailing Address - Fax:515-962-0160
Practice Address - Street 1:301 E HILLCREST AVE
Practice Address - Street 2:
Practice Address - City:INDIANOLA
Practice Address - State:IA
Practice Address - Zip Code:50125-9027
Practice Address - Country:US
Practice Address - Phone:515-961-3700
Practice Address - Fax:515-962-0160
Is Sole Proprietor?:No
Enumeration Date:2007-12-03
Last Update Date:2014-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085003069363A00000X
IA002089363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA719260446Medicare PIN
ILP00680756Medicare PIN