Provider Demographics
NPI:1215332986
Name:GONZALES, JAMIE ELISE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:JAMIE
Middle Name:ELISE
Last Name:GONZALES
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MRS
Other - First Name:JAMIE
Other - Middle Name:ELISE
Other - Last Name:TROUPE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:112 AIRPORT BUSINESS PARK DR
Mailing Address - Street 2:STE H
Mailing Address - City:SHELBYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37160-7452
Mailing Address - Country:US
Mailing Address - Phone:931-680-6360
Mailing Address - Fax:
Practice Address - Street 1:112 AIRPORT BUSINESS PARK DR
Practice Address - Street 2:STE H
Practice Address - City:SHELBYVILLE
Practice Address - State:TN
Practice Address - Zip Code:37160-7452
Practice Address - Country:US
Practice Address - Phone:931-680-6360
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-23
Last Update Date:2014-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2652363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical