Provider Demographics
NPI:1083769590
Name:GILBERT, NICHOLAS ROY (APRN)
Entity Type:Individual
Prefix:MR
First Name:NICHOLAS
Middle Name:ROY
Last Name:GILBERT
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:152 SIMSBURY RD
Mailing Address - Street 2:BUILDING 9, 2ND FLOOR, VISTA
Mailing Address - City:AVON
Mailing Address - State:CT
Mailing Address - Zip Code:06001-3777
Mailing Address - Country:US
Mailing Address - Phone:860-269-3101
Mailing Address - Fax:860-269-3102
Practice Address - Street 1:152 SIMSBURY RD
Practice Address - Street 2:BUILDING 9, 2ND FLOOR
Practice Address - City:AVON
Practice Address - State:CT
Practice Address - Zip Code:06001-3777
Practice Address - Country:US
Practice Address - Phone:860-269-3101
Practice Address - Fax:860-269-3102
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2011-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000976364SP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008004080Medicaid
CT008004080Medicaid