Basic Information
Provider Information | |||||||||
NPI: | 1881903649 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SINCLAIR | ||||||||
FirstName: | GRETCHEN | ||||||||
MiddleName: | MARIA | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | FNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 1239 | ||||||||
Address2: |   | ||||||||
City: | TROY | ||||||||
State: | MI | ||||||||
PostalCode: | 480991239 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2488246600 | ||||||||
FaxNumber: | 8556186655 | ||||||||
Practice Location | |||||||||
Address1: | 4800 FREDERICKSBURG RD | ||||||||
Address2: | SUITE 127 | ||||||||
City: | SAN ANTONIO | ||||||||
State: | TX | ||||||||
PostalCode: | 782293628 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2107335072 | ||||||||
FaxNumber: | 2107338649 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/28/2010 | ||||||||
LastUpdateDate: | 07/10/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 714323 | TX | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363L00000X | 714323 | TX | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   |
ID Information
ID | Type | State | Issuer | Description | 219545501 | 05 | TX |   | MEDICAID |