Provider Demographics
NPI:1710696976
Name:GILLISPIE, MICHAEL PAUL (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:PAUL
Last Name:GILLISPIE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1735 27TH ST STE B06
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:OH
Mailing Address - Zip Code:45662-2681
Mailing Address - Country:US
Mailing Address - Phone:740-356-8681
Mailing Address - Fax:740-356-1256
Practice Address - Street 1:1805 27TH ST
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:OH
Practice Address - Zip Code:45662-2686
Practice Address - Country:US
Practice Address - Phone:740-356-8117
Practice Address - Fax:740-353-1214
Is Sole Proprietor?:No
Enumeration Date:2022-11-16
Last Update Date:2023-06-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OH50.007812RX363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant