Provider Demographics
NPI:1487629440
Name:ATCHISON, GINA THERESA (PA)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:THERESA
Last Name:ATCHISON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1110 OAKWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:OAKWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:45419-2911
Mailing Address - Country:US
Mailing Address - Phone:937-885-7163
Mailing Address - Fax:
Practice Address - Street 1:7073 CLYO RD
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:45459-4816
Practice Address - Country:US
Practice Address - Phone:937-435-5857
Practice Address - Fax:937-912-4960
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-22
Last Update Date:2019-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50-00-1815207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHATPA19242Medicare PIN
OHP63609Medicare UPIN