Provider Demographics
NPI:1508115965
Name:GAISHIN, TAMARA NICHOLE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:TAMARA
Middle Name:NICHOLE
Last Name:GAISHIN
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 1:4025 HEALTH PARK LN
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-3421
Mailing Address - Country:US
Mailing Address - Phone:269-429-7100
Mailing Address - Fax:269-429-1959
Practice Address - Street 1:4025 HEALTH PARK LN
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-3421
Practice Address - Country:US
Practice Address - Phone:269-429-7100
Practice Address - Fax:269-429-1959
Is Sole Proprietor?:No
Enumeration Date:2012-08-31
Last Update Date:2016-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIL2304186363A00000X
MI5601006446363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5601006446OtherSTATE LICENSE
MI1508115965Medicaid
MI1508115965Medicaid