Provider Demographics
NPI:1619094174
Name:MICHAELMAN, GWENDOLYN BRUCH (PA)
Entity Type:Individual
Prefix:MS
First Name:GWENDOLYN
Middle Name:BRUCH
Last Name:MICHAELMAN
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 1:2727 W DR MARTIN LUTHER KING JR BLVD
Mailing Address - Street 2:SUITE NUMBER 300
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33607-6383
Mailing Address - Country:US
Mailing Address - Phone:813-874-5707
Mailing Address - Fax:
Practice Address - Street 1:3001 W DR MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-6307
Practice Address - Country:US
Practice Address - Phone:813-870-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTQ62542363AM0700X
FLPA9104166363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL292912100Medicaid
CTQ62542Medicare UPIN
FL292912100Medicaid