Provider Demographics
NPI:1417902545
Name:WEST, GARY (PA)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:WEST
Suffix:
Gender:M
Credentials:PA
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 328
Mailing Address - Street 2:
Mailing Address - City:SIOUX CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51102-0328
Mailing Address - Country:US
Mailing Address - Phone:712-279-5830
Mailing Address - Fax:712-279-5883
Practice Address - Street 1:615 E 14TH ST
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:NE
Practice Address - Zip Code:68787-1152
Practice Address - Country:US
Practice Address - Phone:402-375-2500
Practice Address - Fax:402-375-2463
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2007-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE56363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE970022470Medicare ID - Type UnspecifiedRR MD
R81634Medicare UPIN
NE274759Medicare PIN