Provider Demographics
NPI:1861400665
Name:EHLE, GREGORY LAWRENCE (MMSC, PA-C)
Entity type:Individual
Prefix:PROF
First Name:GREGORY
Middle Name:LAWRENCE
Last Name:EHLE
Suffix:
Gender:M
Credentials:MMSC, PA-C
Other - Prefix:
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Mailing Address - Street 1:439 BIG HOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:STARKSBORO
Mailing Address - State:VT
Mailing Address - Zip Code:05487-7273
Mailing Address - Country:US
Mailing Address - Phone:802-453-3919
Mailing Address - Fax:
Practice Address - Street 1:111 COLCHESTER AVE
Practice Address - Street 2:MCCLURE 1 CARDIOLOGY
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401-1473
Practice Address - Country:US
Practice Address - Phone:802-847-3352
Practice Address - Fax:802-847-8818
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VT0550030643363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1009842Medicaid
VTP01627Medicare UPIN
VT1009842Medicaid