Provider Demographics
NPI:1932245560
Name:GOMOLL, JILL ANNE (PA-C)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:ANNE
Last Name:GOMOLL
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 1:1031 E SAGINAW ST
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48906-5519
Mailing Address - Country:US
Mailing Address - Phone:517-487-1003
Mailing Address - Fax:517-487-1129
Practice Address - Street 1:1031 E SAGINAW ST
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48906-5519
Practice Address - Country:US
Practice Address - Phone:517-487-1003
Practice Address - Fax:517-487-1129
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2013-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601004130363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIQ75706Medicare UPIN
MIN61290009Medicare ID - Type UnspecifiedMEDICARE