Healthcare Provider Details

I. General information

NPI: 1649462664
Provider Name (Legal Business Name): AMBER RAE GEBHARDT PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/14/2007
Last Update Date: 11/27/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 MALTESE DR
MIDDLETOWN NY
10940-2115
US

IV. Provider business mailing address

111 MALTESE DR
MIDDLETOWN NY
10940-2115
US

V. Phone/Fax

Practice location:
  • Phone: 845-342-4774
  • Fax:
Mailing address:
  • Phone: 845-342-4774
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number25MP00184400
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number013604-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: