Provider Demographics
NPI:1588758700
Name:FAWCETT, GRETCHEN WAYNE (PA-C)
Entity type:Individual
Prefix:
First Name:GRETCHEN
Middle Name:WAYNE
Last Name:FAWCETT
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 1:180 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:IL
Mailing Address - Zip Code:61520-2608
Mailing Address - Country:US
Mailing Address - Phone:309-647-0201
Mailing Address - Fax:309-649-5101
Practice Address - Street 1:408 S MAIN ST
Practice Address - Street 2:
Practice Address - City:LEWISTOWN
Practice Address - State:IL
Practice Address - Zip Code:61542-1563
Practice Address - Country:US
Practice Address - Phone:309-547-9700
Practice Address - Fax:309-649-6880
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2021-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL85001592363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP45737Medicare UPIN
ILIL2868138Medicare PIN