Provider Demographics
NPI:1376689851
Name:PREGO, GILSON (PAC)
Entity type:Individual
Prefix:MR
First Name:GILSON
Middle Name:
Last Name:PREGO
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:705 8TH ST
Mailing Address - Street 2:#2
Mailing Address - City:SECAUCUS
Mailing Address - State:NJ
Mailing Address - Zip Code:07094-3019
Mailing Address - Country:US
Mailing Address - Phone:201-210-2551
Mailing Address - Fax:
Practice Address - Street 1:506 MALCOLM X BLVD
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10037-1802
Practice Address - Country:US
Practice Address - Phone:212-939-4335
Practice Address - Fax:212-939-4344
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2012-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY5141-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant