Individual
MR. LEON GAUTHIER
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA-C
Contact information
Practice address
220 N PARK AVE, SUITE 2, HERRIN, IL 62948-3150
(618) 942-3344
(618) 942-5045
Mailing address
220 N PARK AVE, SUITE 2, HERRIN, IL 62948-3150
(618) 942-3344
(618) 942-5045
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
085000934
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
371359450
FEDERAL EMPLOYER ID NUMBE
IL
01
—
441379
HEALTHLINK HMO/PPO PROV #
IL
01
—
970023073
RAILROAD PROVIDER NUMBER
IL
01
—
CB3700
RAILROAD MEDICARE GROUP
IL
01
—
L84852
UMWA PROVIDER NUMBER
IL
Enumeration date
06/23/2006
Last updated
07/09/2007
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