Provider Demographics
NPI:1275504243
Name:GILBERT, TONYA T (PA-C)
Entity type:Individual
Prefix:
First Name:TONYA
Middle Name:T
Last Name:GILBERT
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 1:4504 ALEXANDER VALLEY DR APT 202
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28270-1510
Mailing Address - Country:US
Mailing Address - Phone:910-705-6102
Mailing Address - Fax:
Practice Address - Street 1:41800 W 11 MILE RD STE 109
Practice Address - Street 2:
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48375-1818
Practice Address - Country:US
Practice Address - Phone:910-705-6102
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-30
Last Update Date:2025-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIMG134090363A00000X
NC0010-01792363A00000X
PAMA050618363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1275504243Medicaid
PA073742Medicare ID - Type Unspecified