Provider Demographics
NPI:1699290783
Name:SHULL, GRETCHEN LYNNE (PA-C)
Entity type:Individual
Prefix:
First Name:GRETCHEN
Middle Name:LYNNE
Last Name:SHULL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:GRETCHEN
Other - Middle Name:
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:111 NEW HAMPSHIRE AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:NH
Mailing Address - Zip Code:03801-2864
Mailing Address - Country:US
Mailing Address - Phone:802-909-2053
Mailing Address - Fax:
Practice Address - Street 1:7676 REYNOLDS RD
Practice Address - Street 2:
Practice Address - City:MENTOR
Practice Address - State:OH
Practice Address - Zip Code:44060-5110
Practice Address - Country:US
Practice Address - Phone:440-283-3015
Practice Address - Fax:440-283-3010
Is Sole Proprietor?:No
Enumeration Date:2017-08-09
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.007682363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103368190Medicaid