Provider Demographics
NPI:1063474070
Name:CALLAHAN, GINA M (RPA-C)
Entity Type:Individual
Prefix:MRS
First Name:GINA
Middle Name:M
Last Name:CALLAHAN
Suffix:
Gender:F
Credentials:RPA-C
Other - Prefix:
Other - First Name:GINA
Other - Middle Name:M
Other - Last Name:GIANCARLO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:33 LEWIS RD
Mailing Address - Street 2:2ND FL
Mailing Address - City:BINGHAMTON
Mailing Address - State:NY
Mailing Address - Zip Code:13905
Mailing Address - Country:US
Mailing Address - Phone:607-729-8156
Mailing Address - Fax:607-729-3982
Practice Address - Street 1:1302 E MAIN ST
Practice Address - Street 2:
Practice Address - City:ENDICOTT
Practice Address - State:NY
Practice Address - Zip Code:13760-5430
Practice Address - Country:US
Practice Address - Phone:607-754-2323
Practice Address - Fax:607-754-3033
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2018-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011120363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYPA1365Medicare ID - Type Unspecified
NYQ69466Medicare UPIN