Provider Demographics
NPI:1568863843
Name:GENTILE, MICAH
Entity Type:Individual
Prefix:
First Name:MICAH
Middle Name:
Last Name:GENTILE
Suffix:
Gender:M
Credentials:
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 195002
Mailing Address - Street 2:N46 CAPE SARICHEF
Mailing Address - City:KODIAK
Mailing Address - State:AK
Mailing Address - Zip Code:99619-5002
Mailing Address - Country:US
Mailing Address - Phone:907-487-5757
Mailing Address - Fax:907-487-5151
Practice Address - Street 1:15 MOHEGAN AVE
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:CT
Practice Address - Zip Code:06320-8100
Practice Address - Country:US
Practice Address - Phone:860-704-6999
Practice Address - Fax:860-444-8413
Is Sole Proprietor?:No
Enumeration Date:2014-09-05
Last Update Date:2019-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60527256363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant