Provider Demographics
NPI:1295132231
Name:SCANLON, GINA (MPAS, PA-C)
Entity type:Individual
Prefix:
First Name:GINA
Middle Name:
Last Name:SCANLON
Suffix:
Gender:F
Credentials:MPAS, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1231 DEER PARK AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH BABYLON
Mailing Address - State:NY
Mailing Address - Zip Code:11703-3104
Mailing Address - Country:US
Mailing Address - Phone:631-667-0388
Mailing Address - Fax:631-968-7705
Practice Address - Street 1:1600 DEER PARK AVE
Practice Address - Street 2:SUITE G
Practice Address - City:DEER PARK
Practice Address - State:NY
Practice Address - Zip Code:11729-5208
Practice Address - Country:US
Practice Address - Phone:631-667-0388
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-19
Last Update Date:2024-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018262363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical