Provider Demographics
NPI:1528675246
Name:NEEDHAM, GABRIELL MARIE
Entity type:Individual
Prefix:
First Name:GABRIELL
Middle Name:MARIE
Last Name:NEEDHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 174
Mailing Address - Street 2:
Mailing Address - City:POTTERSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12860-0174
Mailing Address - Country:US
Mailing Address - Phone:518-796-7385
Mailing Address - Fax:
Practice Address - Street 1:1419 SALT SPRINGS RD
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13214-1302
Practice Address - Country:US
Practice Address - Phone:518-796-7385
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-27
Last Update Date:2021-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant