Provider Demographics
NPI:1427094895
Name:GOMBETTO, STACEY I (RPA-C)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:GOMBETTO
Suffix:I
Gender:F
Credentials:RPA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1425 PORTLAND AVE
Mailing Address - Street 2:TWIG MEDICAL GROUP
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14621-3001
Mailing Address - Country:US
Mailing Address - Phone:585-922-2197
Mailing Address - Fax:
Practice Address - Street 1:1425 PORTLAND AVE
Practice Address - Street 2:TWIG MEDICAL GROUP
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14621-3001
Practice Address - Country:US
Practice Address - Phone:585-922-2197
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2010-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004655363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02512545Medicaid
NY02512545Medicaid
NYP71019-GRP:70008AMedicare PIN
NYPA0040-GRP:BA0017Medicare PIN
NYJ400021099Medicare PIN