Healthcare Provider Details

I. General information

NPI: 1245740653
Provider Name (Legal Business Name): GEORGE F GEBRAEL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2017
Last Update Date: 10/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

37 W GARDEN ST
AUBURN NY
13021-2662
US

IV. Provider business mailing address

108 KINGS PARK DR APT K
LIVERPOOL NY
13090-4705
US

V. Phone/Fax

Practice location:
  • Phone: 315-252-0000
  • Fax:
Mailing address:
  • Phone: 315-935-0012
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number021471
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: