Basic Information
| Provider Information | |||||||||
| NPI: | 1275770265 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RODRIGUEZ CARABALLO | ||||||||
| FirstName: | GLADYS | ||||||||
| MiddleName: | V | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 207 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | NEWMARKET | ||||||||
| State: | NH | ||||||||
| PostalCode: | 038571835 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6032923061 | ||||||||
| FaxNumber: | 6036595892 | ||||||||
| Practice Location | |||||||||
| Address1: | 207 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | NEWMARKET | ||||||||
| State: | NH | ||||||||
| PostalCode: | 038571835 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6032927292 | ||||||||
| FaxNumber: | 6036595892 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/13/2009 | ||||||||
| LastUpdateDate: | 09/23/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 1020 | NH | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 3096848 | 05 | NH | MEDICAID | 9001140 | 05 | VT | MEDICAID |