Provider Demographics
NPI:1215982624
Name:GULLIFORD, JILL WASSERMAN (PA-C)
Entity type:Individual
Prefix:MRS
First Name:JILL
Middle Name:WASSERMAN
Last Name:GULLIFORD
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:JILL
Other - Middle Name:NICOLE
Other - Last Name:WASSERMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:501 KINGS HWY E
Mailing Address - Street 2:SUITE 112
Mailing Address - City:FAIRFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06825-4867
Mailing Address - Country:US
Mailing Address - Phone:203-382-1900
Mailing Address - Fax:203-382-0019
Practice Address - Street 1:950 CAMPBELL AVE
Practice Address - Street 2:
Practice Address - City:WEST HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06516-2770
Practice Address - Country:US
Practice Address - Phone:203-932-5711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000773363AS0400X
CT00773363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT2V3798OtherHEALTH NET
CT290000773CT01OtherANTHEM BLUE CROSS
CT970001057Medicare ID - Type Unspecified
CT2V3798OtherHEALTH NET