Provider Demographics
NPI:1225419054
Name:BENTLEY, GABRIELLE (PA-C)
Entity Type:Individual
Prefix:
First Name:GABRIELLE
Middle Name:
Last Name:BENTLEY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:GABRIELLE
Other - Middle Name:
Other - Last Name:CONDICT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:2263 STATE HIGHWAY 310
Mailing Address - Street 2:
Mailing Address - City:MADRID
Mailing Address - State:NY
Mailing Address - Zip Code:13660-3224
Mailing Address - Country:US
Mailing Address - Phone:315-322-8947
Mailing Address - Fax:315-713-5246
Practice Address - Street 1:2263 STATE HIGHWAY 310
Practice Address - Street 2:
Practice Address - City:MADRID
Practice Address - State:NY
Practice Address - Zip Code:13660-3224
Practice Address - Country:US
Practice Address - Phone:315-322-8947
Practice Address - Fax:315-713-5246
Is Sole Proprietor?:No
Enumeration Date:2015-06-17
Last Update Date:2022-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018647363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04169751Medicaid