Provider Demographics
NPI:1669065744
Name:MAXWELL, GABRIELLE ELIZABETH (PA-C)
Entity type:Individual
Prefix:
First Name:GABRIELLE
Middle Name:ELIZABETH
Last Name:MAXWELL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:GABRIELLE
Other - Middle Name:ELIZABETH
Other - Last Name:EVANS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:100 SCHUYLKILL MEDICAL PLZ STE 105
Mailing Address - Street 2:
Mailing Address - City:POTTSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17901-3636
Mailing Address - Country:US
Mailing Address - Phone:570-624-4840
Mailing Address - Fax:570-622-7589
Practice Address - Street 1:100 SCHUYLKILL MEDICAL PLZ STE 105
Practice Address - Street 2:
Practice Address - City:POTTSVILLE
Practice Address - State:PA
Practice Address - Zip Code:17901-3636
Practice Address - Country:US
Practice Address - Phone:570-622-4840
Practice Address - Fax:570-622-7589
Is Sole Proprietor?:No
Enumeration Date:2021-02-18
Last Update Date:2022-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA062925363A00000X
PAOA005914363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant