Provider Demographics
NPI:1295011617
Name:FLETCHER, GARY BYRON
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:BYRON
Last Name:FLETCHER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:GARY
Other - Middle Name:
Other - Last Name:FLETCHER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 395
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:OR
Mailing Address - Zip Code:97839-0395
Mailing Address - Country:US
Mailing Address - Phone:541-989-8187
Mailing Address - Fax:
Practice Address - Street 1:111 N COLUMBIA AVENUE
Practice Address - Street 2:
Practice Address - City:CONNELL,
Practice Address - State:WA
Practice Address - Zip Code:99326
Practice Address - Country:US
Practice Address - Phone:509-234-7766
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-31
Last Update Date:2017-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA 10002583363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical