Provider Demographics
NPI:1902861164
Name:GAUTHIER, MELISSA J (PA C)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:J
Last Name:GAUTHIER
Suffix:
Gender:F
Credentials:PA C
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Mailing Address - Street 1:1306 MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:ELDORADO
Mailing Address - State:IL
Mailing Address - Zip Code:62930-1662
Mailing Address - Country:US
Mailing Address - Phone:618-273-3361
Mailing Address - Fax:618-297-9669
Practice Address - Street 1:1306 MAPLE ST
Practice Address - Street 2:
Practice Address - City:ELDORADO
Practice Address - State:IL
Practice Address - Zip Code:62930-1662
Practice Address - Country:US
Practice Address - Phone:618-273-3361
Practice Address - Fax:618-297-9669
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2022-04-22
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IL085.000899363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant