Provider Demographics
NPI:1306000377
Name:MIGNONE-GORDON, MICHELE LYNN (PAC)
Entity Type:Individual
Prefix:MRS
First Name:MICHELE
Middle Name:LYNN
Last Name:MIGNONE-GORDON
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:PO BOX 2709
Mailing Address - Street 2:
Mailing Address - City:ZEPHYRHILLS
Mailing Address - State:FL
Mailing Address - Zip Code:33539-2709
Mailing Address - Country:US
Mailing Address - Phone:813-788-1400
Mailing Address - Fax:813-788-7691
Practice Address - Street 1:38035 MEDICAL CENTER AVE
Practice Address - Street 2:
Practice Address - City:ZEPHYRHILLS
Practice Address - State:FL
Practice Address - Zip Code:33540-1384
Practice Address - Country:US
Practice Address - Phone:813-788-1400
Practice Address - Fax:813-788-7691
Is Sole Proprietor?:No
Enumeration Date:2008-07-17
Last Update Date:2016-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9104644363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPA9104644OtherFL LICENSE