Provider Demographics
NPI:1790747665
Name:MINDOCK, GREGORY P (PA-C)
Entity Type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:P
Last Name:MINDOCK
Suffix:
Gender:M
Credentials:PA-C
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Mailing Address - Street 1:5943 STADIUM DR
Mailing Address - Street 2:STE 1
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49009-3016
Mailing Address - Country:US
Mailing Address - Phone:269-552-2836
Mailing Address - Fax:269-552-2964
Practice Address - Street 1:8906 M 89
Practice Address - Street 2:
Practice Address - City:RICHLAND
Practice Address - State:MI
Practice Address - Zip Code:49083
Practice Address - Country:US
Practice Address - Phone:269-286-7130
Practice Address - Fax:269-286-7131
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2023-11-27
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Provider Licenses
StateLicense IDTaxonomies
MI5601001086363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q56373Medicare UPIN