Provider Demographics
NPI:1073180550
Name:WILBER, GINA LUCARELLI (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:GINA
Middle Name:LUCARELLI
Last Name:WILBER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:80 CLUB DR
Mailing Address - Street 2:
Mailing Address - City:BERLIN
Mailing Address - State:CT
Mailing Address - Zip Code:06037-1132
Mailing Address - Country:US
Mailing Address - Phone:860-221-5556
Mailing Address - Fax:
Practice Address - Street 1:27 RANDOLPH RD
Practice Address - Street 2:
Practice Address - City:HOWELL
Practice Address - State:NJ
Practice Address - Zip Code:07731-8611
Practice Address - Country:US
Practice Address - Phone:866-415-8251
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-04
Last Update Date:2022-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT5264363A00000X, 363AM0700X
CT0052642084P0805X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric Psychiatry
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical