Healthcare Provider Details

I. General information

NPI: 1215982624
Provider Name (Legal Business Name): JILL WASSERMAN GULLIFORD PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JILL NICOLE WASSERMAN PA-C

II. Dates (important events)

Enumeration Date: 05/23/2006
Last Update Date: 09/11/2023
Certification Date: 09/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

950 CAMPBELL AVE
WEST HAVEN CT
06516-2770
US

IV. Provider business mailing address

501 KINGS HWY E SUITE 112
FAIRFIELD CT
06825-4867
US

V. Phone/Fax

Practice location:
  • Phone: 203-932-5711
  • Fax:
Mailing address:
  • Phone: 203-382-1900
  • Fax: 203-382-0019

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number000773
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number00773
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: