Provider Demographics
NPI:1851363956
Name:GLOOD, MICHELE T (PA C)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:T
Last Name:GLOOD
Suffix:
Gender:F
Credentials:PA C
Other - Prefix:
Other - First Name:MICHELE
Other - Middle Name:
Other - Last Name:TRACH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8170 33RD AVE S # MS 21110Q
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55425-4516
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15290 PENNOCK LN
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55124-7163
Practice Address - Country:US
Practice Address - Phone:952-853-8800
Practice Address - Fax:952-431-6966
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2021-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10012363A00000X
WI1929363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42877600Medicaid
WI42877600Medicaid