Provider Demographics
NPI:1184630766
Name:KINGSLEY, GERALD SCOTT (RPAC)
Entity Type:Individual
Prefix:MR
First Name:GERALD
Middle Name:SCOTT
Last Name:KINGSLEY
Suffix:
Gender:M
Credentials:RPAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1299 PORTLAND AVE
Mailing Address - Street 2:SUITE 16
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14621
Mailing Address - Country:US
Mailing Address - Phone:585-266-3300
Mailing Address - Fax:585-266-2163
Practice Address - Street 1:1299 PORTLAND AVE
Practice Address - Street 2:SUITE 16
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14621
Practice Address - Country:US
Practice Address - Phone:585-266-3300
Practice Address - Fax:585-266-2163
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY5800363A00000X
NY0058001363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P019005800OtherBCBS
5289364OtherAETNA
108925CUOtherPRECARE
5289364OtherAETNA