Basic Information
| Provider Information | |||||||||
| NPI: | 1154513752 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GATHAIYA | ||||||||
| FirstName: | NICOLA | ||||||||
| MiddleName: | W | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MWIRIGI | ||||||||
| OtherFirstName: | NICOLA | ||||||||
| OtherMiddleName: | W | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.B.B.S. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 960 E. WALNUT LAWN | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 65807 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4172694450 | ||||||||
| FaxNumber: | 4172698333 | ||||||||
| Practice Location | |||||||||
| Address1: | 960 E. WALNUT LAWN | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 65807 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4172694450 | ||||||||
| FaxNumber: | 4172698333 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2007 | ||||||||
| LastUpdateDate: | 03/07/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207RE0101X | 51914 | MN | N | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism | 207RE0101X | 2013003418 | MO | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism |
ID Information
| ID | Type | State | Issuer | Description | ENROLLED | 05 | MN | MEDICAID | P00864005 | 01 | MN | MEDICARE RAILROAD | OTHER | ENROLLED | 05 | IA | MEDICAID |