=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326406224
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GEROME MEDINACELI GEPIGON PA-C
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/05/2016
-----------------------------------------------------
Last Update Date | 09/16/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 399 FARMINGTON AVE STE 210
-----------------------------------------------------
City | FARMINGTON
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06032-1944
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-548-7338
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1290 SILAS DEANE HWY
-----------------------------------------------------
City | WETHERSFIELD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06109-4337
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-972-9033
-----------------------------------------------------
Fax | 860-972-7040
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AS0400X
-----------------------------------------------------
Taxonomy Name | Surgical Physician Assistant
-----------------------------------------------------
License Number | 6763
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363AS0400X
-----------------------------------------------------
Taxonomy Name | Surgical Physician Assistant
-----------------------------------------------------
License Number | 1145
-----------------------------------------------------
License Number State | NH
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 363AS0400X
-----------------------------------------------------
Taxonomy Name | Surgical Physician Assistant
-----------------------------------------------------
License Number | 61032719
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------