Provider Demographics
NPI:1184652711
Name:RUPERT, GINA (PAC)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:
Last Name:RUPERT
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:385 MAIN ST SOUTH
Mailing Address - Street 2:STE 301 UNION SQUARE
Mailing Address - City:SOUTHBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06488
Mailing Address - Country:US
Mailing Address - Phone:203-264-3319
Mailing Address - Fax:203-267-6382
Practice Address - Street 1:385 MAIN ST SOUTH
Practice Address - Street 2:STE 301 UNION SQUARE
Practice Address - City:SOUTHBURY
Practice Address - State:CT
Practice Address - Zip Code:06488
Practice Address - Country:US
Practice Address - Phone:203-264-3319
Practice Address - Fax:203-267-6382
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2021-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001710363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT970002144Medicare ID - Type Unspecified
Q68397Medicare UPIN