Provider Demographics
NPI:1821219080
Name:GERCKENS, PATSY (PA)
Entity Type:Individual
Prefix:MS
First Name:PATSY
Middle Name:
Last Name:GERCKENS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 N COLONY RD
Mailing Address - Street 2:STE 101
Mailing Address - City:WALLINGFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06492-2407
Mailing Address - Country:US
Mailing Address - Phone:203-732-1330
Mailing Address - Fax:203-732-1332
Practice Address - Street 1:110 COMMERCE DR
Practice Address - Street 2:
Practice Address - City:SHELTON
Practice Address - State:CT
Practice Address - Zip Code:06484-6244
Practice Address - Country:US
Practice Address - Phone:203-929-7331
Practice Address - Fax:203-925-0330
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000791363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT97000986Medicare ID - Type Unspecified
CTP00019Medicare UPIN