Healthcare Provider Details

I. General information

NPI: 1215512876
Provider Name (Legal Business Name): GILLIAN DIBICH PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2021
Last Update Date: 03/03/2026
Certification Date: 03/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

90 PRESIDENTIAL PLAZA
SYRACUSE NY
13202
US

IV. Provider business mailing address

251 SALINA MEADOWS PARKWAY SUITE 100
SYRACUSE NY
13212
US

V. Phone/Fax

Practice location:
  • Phone: 315-464-3833
  • Fax: 315-464-3791
Mailing address:
  • Phone: 315-464-2000
  • Fax: 315-464-2010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number034823
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: