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General NPI Number Information
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NPI Number | 1154505303
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Entity Type | Individual
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Provider Name | JACQUELINE GRACE GIL RPA-C
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Gender | Female
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Dates
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Enumeration Date | 12/24/2007
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Last Update Date | 12/24/2007
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Provider Practice Location Address
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Address Line | 445 MAIN ST # 1128
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City | CENTER MORICHES
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State | NY
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Zip | 11934-3512
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Country | US
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Telephone | 631-878-1043
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Fax |
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Provider Business Mailing Address
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Address Line | 445 MAIN ST BOX 1128
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City | CENTER MORICHES
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State | NY
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Zip | 11934
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Country | US
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Telephone | 631-878-1043
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | 23 012327
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License Number State | NY
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