Provider Demographics
NPI:1881704765
Name:TROWBRIDGE, GARY W (PA)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:W
Last Name:TROWBRIDGE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1033 N INDIANA AVE
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:IN
Mailing Address - Zip Code:46567-1017
Mailing Address - Country:US
Mailing Address - Phone:574-457-5701
Mailing Address - Fax:574-457-5609
Practice Address - Street 1:1033 N INDIANA AVE
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:IN
Practice Address - Zip Code:46567-1017
Practice Address - Country:US
Practice Address - Phone:574-457-5701
Practice Address - Fax:574-457-5609
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2014-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10000351A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN184520010Medicare PIN