Provider Demographics
NPI:1457723538
Name:GILLESPIE, SETH E (PA-C)
Entity Type:Individual
Prefix:
First Name:SETH
Middle Name:E
Last Name:GILLESPIE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1533 E. WILLETTA ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85006
Mailing Address - Country:US
Mailing Address - Phone:602-569-3999
Mailing Address - Fax:602-569-3887
Practice Address - Street 1:1533 E WILLETTA ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85006-2935
Practice Address - Country:US
Practice Address - Phone:602-569-3999
Practice Address - Fax:602-569-3887
Is Sole Proprietor?:No
Enumeration Date:2015-10-28
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6254363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ078353Medicaid
AZ078353Medicaid