Provider Demographics
NPI:1871571356
Name:GUNNISON, ALICE C (PA C)
Entity type:Individual
Prefix:
First Name:ALICE
Middle Name:C
Last Name:GUNNISON
Suffix:
Gender:F
Credentials:PA C
Other - Prefix:
Other - First Name:ALICE
Other - Middle Name:
Other - Last Name:STEWART
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2406 WEST BROADWAY
Mailing Address - Street 2:JENCARE NEIGHBORHOOD MEDICAL CENTER WEST BROADWAY, LLC
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40211
Mailing Address - Country:US
Mailing Address - Phone:502-775-1211
Mailing Address - Fax:502-775-1221
Practice Address - Street 1:2406 WEST BROADWAY
Practice Address - Street 2:JENCARE NEIGHBORHOOD MEDICAL CENTER WEST BROADWAY, LLC
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40211
Practice Address - Country:US
Practice Address - Phone:502-775-1211
Practice Address - Fax:502-775-1221
Is Sole Proprietor?:No
Enumeration Date:2006-01-05
Last Update Date:2015-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA159363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY95001590Medicaid
KY1271139Medicare ID - Type Unspecified
KY95001590Medicaid
KY0773805Medicare PIN