Provider Demographics
NPI:1902975055
Name:GAMMELIN, ELISABETH LUISE (PA)
Entity Type:Individual
Prefix:
First Name:ELISABETH
Middle Name:LUISE
Last Name:GAMMELIN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:283 N 1ST E
Mailing Address - Street 2:
Mailing Address - City:DRIGGS
Mailing Address - State:ID
Mailing Address - Zip Code:83422-5109
Mailing Address - Country:US
Mailing Address - Phone:208-354-2302
Mailing Address - Fax:208-354-8392
Practice Address - Street 1:1 LAKE STATION
Practice Address - Street 2:LAKE CLINIC
Practice Address - City:YELLOWSTONE NATIONAL PARK
Practice Address - State:WY
Practice Address - Zip Code:82190
Practice Address - Country:US
Practice Address - Phone:307-242-7241
Practice Address - Fax:307-242-7273
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2009-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-448363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806724500Medicaid
ID1665363Medicare ID - Type UnspecifiedMEDICARE INDIVIDUAL
ID806724500Medicaid