Healthcare Provider Details

I. General information

NPI: 1912966490
Provider Name (Legal Business Name): PHILIP N. GILLEMOT PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2006
Last Update Date: 03/22/2021
Certification Date: 03/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 1ST ST
WATKINS GLEN NY
14891-1260
US

IV. Provider business mailing address

1 GUTHRIE SQ
SAYRE PA
18840-1625
US

V. Phone/Fax

Practice location:
  • Phone: 607-535-2403
  • Fax: 607-535-2537
Mailing address:
  • Phone: 570-888-5858
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number009351-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: