Provider Demographics
NPI:1063042604
Name:VICENCIO, GILBERT B (MSN, FNP-BC)
Entity Type:Individual
Prefix:MR
First Name:GILBERT
Middle Name:B
Last Name:VICENCIO
Suffix:
Gender:M
Credentials:MSN, FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 EVERGREEN RD
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:NJ
Mailing Address - Zip Code:08873-2822
Mailing Address - Country:US
Mailing Address - Phone:732-690-9479
Mailing Address - Fax:
Practice Address - Street 1:254 EASTON AVE
Practice Address - Street 2:
Practice Address - City:NEW BRUNSWICK
Practice Address - State:NJ
Practice Address - Zip Code:08901-1766
Practice Address - Country:US
Practice Address - Phone:732-745-6671
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-23
Last Update Date:2020-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00997100363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily