Provider Demographics
NPI:1790760866
Name:BUREAU, GINO (PT)
Entity Type:Individual
Prefix:
First Name:GINO
Middle Name:
Last Name:BUREAU
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1A WEST DR
Mailing Address - Street 2:
Mailing Address - City:CASTLETON
Mailing Address - State:NY
Mailing Address - Zip Code:12033-9524
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 CONWAY CT
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:NY
Practice Address - Zip Code:12180-2108
Practice Address - Country:US
Practice Address - Phone:518-273-4350
Practice Address - Fax:518-273-7350
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007820-1174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYAA0454Medicare ID - Type Unspecified