Provider Demographics
NPI:1033656715
Name:JUPITER, GABOY (NP)
Entity Type:Individual
Prefix:
First Name:GABOY
Middle Name:
Last Name:JUPITER
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:MEDICAL CENTER BLVD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27157-0001
Mailing Address - Country:US
Mailing Address - Phone:336-716-9252
Mailing Address - Fax:336-716-0030
Practice Address - Street 1:MEDICAL CENTER BLVD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27157-9130
Practice Address - Country:US
Practice Address - Phone:336-716-9252
Practice Address - Fax:336-716-0030
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-19
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5017243363L00000X
CT10286363L00000X, 363LF0000X
MECNP211642363L00000X
NY431172363L00000X
CA95005814363LA2100X
GARN275508363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily