Provider Demographics
NPI:1063419695
Name:SUTTON, GRETCHEN L (PA)
Entity type:Individual
Prefix:
First Name:GRETCHEN
Middle Name:L
Last Name:SUTTON
Suffix:
Gender:
Credentials:PA
Other - Prefix:
Other - First Name:GRETCHEN
Other - Middle Name:L
Other - Last Name:PHELPS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:272 COUNTRY RD 300 N
Mailing Address - Street 2:
Mailing Address - City:NORRIS CITY
Mailing Address - State:IL
Mailing Address - Zip Code:62869
Mailing Address - Country:US
Mailing Address - Phone:618-599-2663
Mailing Address - Fax:
Practice Address - Street 1:1300 US HIGHWAY 45 N
Practice Address - Street 2:
Practice Address - City:ELDORADO
Practice Address - State:IL
Practice Address - Zip Code:62930-3765
Practice Address - Country:US
Practice Address - Phone:618-297-9660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-28
Last Update Date:2025-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085001662363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILQ39323Medicare UPIN
ILK15955Medicare ID - Type Unspecified