Provider Demographics
NPI:1457328833
Name:GENTNER, BETH MACK (PA-C)
Entity Type:Individual
Prefix:
First Name:BETH
Middle Name:MACK
Last Name:GENTNER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5163 E HOLLY RD
Mailing Address - Street 2:
Mailing Address - City:HOLLY
Mailing Address - State:MI
Mailing Address - Zip Code:48442-9746
Mailing Address - Country:US
Mailing Address - Phone:248-634-8840
Mailing Address - Fax:
Practice Address - Street 1:102 N ADELAIDE ST
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MI
Practice Address - Zip Code:48430-2670
Practice Address - Country:US
Practice Address - Phone:810-629-2245
Practice Address - Fax:810-629-6535
Is Sole Proprietor?:No
Enumeration Date:2006-03-03
Last Update Date:2009-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601002066363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMM0921735OtherMEDICARE RR ID
MIW44784Medicare UPIN
MIN90460003Medicare ID - Type UnspecifiedMEDICARE ID