Healthcare Provider Details

I. General information

NPI: 1326406224
Provider Name (Legal Business Name): GEROME MEDINACELI GEPIGON PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/05/2016
Last Update Date: 09/16/2024
Certification Date: 09/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

399 FARMINGTON AVE STE 210
FARMINGTON CT
06032-1944
US

IV. Provider business mailing address

1290 SILAS DEANE HWY
WETHERSFIELD CT
06109-4337
US

V. Phone/Fax

Practice location:
  • Phone: 860-548-7338
  • Fax:
Mailing address:
  • Phone: 860-972-9033
  • Fax: 860-972-7040

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number6763
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number1145
License Number StateNH
# 3
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number61032719
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: