Provider Demographics
NPI:1679114763
Name:DIX, GABRIELLE (PA)
Entity Type:Individual
Prefix:
First Name:GABRIELLE
Middle Name:
Last Name:DIX
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:GABRIELLE
Other - Middle Name:
Other - Last Name:GRAVINO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:100 KINGS HWY S
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14617-5504
Mailing Address - Country:US
Mailing Address - Phone:585-922-5067
Mailing Address - Fax:585-922-2908
Practice Address - Street 1:1425 PORTLAND AVE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14621-3011
Practice Address - Country:US
Practice Address - Phone:585-922-5067
Practice Address - Fax:585-922-2908
Is Sole Proprietor?:No
Enumeration Date:2019-10-01
Last Update Date:2022-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024061363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical