Provider Demographics
NPI:1134194798
Name:GERDON, VICKIE CHRISTINE (PA-C)
Entity type:Individual
Prefix:
First Name:VICKIE
Middle Name:CHRISTINE
Last Name:GERDON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:VICKIE
Other - Middle Name:CHRISTINE
Other - Last Name:GERDON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA-C
Mailing Address - Street 1:1131 WEST ST
Mailing Address - Street 2:
Mailing Address - City:SOUTHINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06489-6006
Mailing Address - Country:US
Mailing Address - Phone:860-621-7682
Mailing Address - Fax:
Practice Address - Street 1:1131 WEST ST
Practice Address - Street 2:
Practice Address - City:SOUTHINGTON
Practice Address - State:CT
Practice Address - Zip Code:06489-6006
Practice Address - Country:US
Practice Address - Phone:860-621-7682
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2012-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000428363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT000428OtherCTCARE PROVIDER #
CT217217OtherPREFERRED ONE
CT000428OtherCTCARE PROVIDER #