Provider Demographics
NPI:1891760526
Name:SPINNER, GARY (PA)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:SPINNER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:400 COLUMBUS AVE
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06519-1233
Mailing Address - Country:US
Mailing Address - Phone:203-503-3250
Mailing Address - Fax:203-503-3254
Practice Address - Street 1:46 ALBION ST
Practice Address - Street 2:SOUTHWEST COMMUNITY HEALTH CENTER, INC
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06605-2602
Practice Address - Country:US
Practice Address - Phone:203-330-6000
Practice Address - Fax:203-330-6007
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2014-07-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CT000050363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001178060Medicaid
CT001178060Medicaid
CT970001075Medicare ID - Type Unspecified