Provider Demographics
NPI:1770603755
Name:GILBERG, GLENN (PA)
Entity type:Individual
Prefix:
First Name:GLENN
Middle Name:
Last Name:GILBERG
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 LANSING ST
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:NY
Mailing Address - Zip Code:13021-1983
Mailing Address - Country:US
Mailing Address - Phone:315-255-7011
Mailing Address - Fax:
Practice Address - Street 1:6870 E GENESEE ST
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NY
Practice Address - Zip Code:13066-1031
Practice Address - Country:US
Practice Address - Phone:315-679-4367
Practice Address - Fax:315-679-4368
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-31
Last Update Date:2023-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
NY006260363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ64509Medicare UPIN
NY6142L1Medicare ID - Type Unspecified