Provider Demographics
NPI:1871675702
Name:GADDY, MICHAEL K (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:K
Last Name:GADDY
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 2580
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65801-2580
Mailing Address - Country:US
Mailing Address - Phone:417-829-4620
Mailing Address - Fax:417-829-4316
Practice Address - Street 1:104 EAST HIGHWAY 60
Practice Address - Street 2:
Practice Address - City:MOUNTAIN VIEW
Practice Address - State:MO
Practice Address - Zip Code:65548
Practice Address - Country:US
Practice Address - Phone:417-934-2251
Practice Address - Fax:417-934-2871
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2008-07-15
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MO112033363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO000097160Medicare PIN
MOP15811Medicare UPIN