Provider Demographics
NPI:1497895387
Name:BROWN, GRETCHEN L (PA)
Entity Type:Individual
Prefix:
First Name:GRETCHEN
Middle Name:L
Last Name:BROWN
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:PO BOX 248
Mailing Address - Street 2:
Mailing Address - City:ELLICOTTVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14731-0248
Mailing Address - Country:US
Mailing Address - Phone:716-699-9032
Mailing Address - Fax:716-699-9035
Practice Address - Street 1:8003 BREWERTON RD
Practice Address - Street 2:
Practice Address - City:CICERO
Practice Address - State:NY
Practice Address - Zip Code:13039-9528
Practice Address - Country:US
Practice Address - Phone:315-288-4006
Practice Address - Fax:315-288-4760
Is Sole Proprietor?:No
Enumeration Date:2007-02-08
Last Update Date:2014-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008324207P00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1056Medicare ID - Type Unspecified
P95448Medicare UPIN