Provider Demographics
NPI:1316003908
Name:GASTON, SAMUEL W (PA)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:W
Last Name:GASTON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:263 FARMINGTON AVE
Mailing Address - Street 2:PROVIDER ENROLLMENT
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06030-2212
Mailing Address - Country:US
Mailing Address - Phone:860-679-7503
Mailing Address - Fax:860-679-1610
Practice Address - Street 1:263 FARMINGTON AVE
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06030-0001
Practice Address - Country:US
Practice Address - Phone:860-679-2290
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2022-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000828363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1316003908Medicaid
CT1316003908Medicaid