Provider Demographics
NPI:1801990353
Name:GAMBREL, MICHELE LEIGH (PA-C)
Entity type:Individual
Prefix:MRS
First Name:MICHELE
Middle Name:LEIGH
Last Name:GAMBREL
Suffix:
Gender:F
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 1:201 OAK DR SOUTH #107
Mailing Address - Street 2:
Mailing Address - City:LAKE JACKSON
Mailing Address - State:TX
Mailing Address - Zip Code:77566-5626
Mailing Address - Country:US
Mailing Address - Phone:979-297-0028
Mailing Address - Fax:979-297-0504
Practice Address - Street 1:201 OAK DR SOUTH #107
Practice Address - Street 2:
Practice Address - City:LAKE JACKSON
Practice Address - State:TX
Practice Address - Zip Code:77566-5626
Practice Address - Country:US
Practice Address - Phone:979-297-0028
Practice Address - Fax:979-297-0504
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-12
Last Update Date:2008-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA00543363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00834YOtherMEDICARE GROUP NUMBER
TXPA00543OtherSTATE LICENSE NUMBER
TXPA00543OtherSTATE LICENSE NUMBER
TXS27053Medicare UPIN