Provider Demographics
NPI:1598865099
Name:GMACH, MARY T (PA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:T
Last Name:GMACH
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 628296
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32862-8296
Mailing Address - Country:US
Mailing Address - Phone:407-741-9418
Mailing Address - Fax:904-346-0113
Practice Address - Street 1:1414 S ORANGE AVE
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-2134
Practice Address - Country:US
Practice Address - Phone:407-841-5111
Practice Address - Fax:904-346-0113
Is Sole Proprietor?:No
Enumeration Date:2006-09-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA0001969363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP11236Medicare UPIN
FLE4402ZMedicare ID - Type Unspecified