Basic Information
| Provider Information | |||||||||
| NPI: | 1609218668 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HEPBURN | ||||||||
| FirstName: | GILLIAN | ||||||||
| MiddleName: | FABIAN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 39 WILLIAM ST | ||||||||
| Address2: | |||||||||
| City: | WALLINGFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064923625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2039872621 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1450 CHAPEL ST | ||||||||
| Address2: | |||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065114405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037893000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2013 | ||||||||
| LastUpdateDate: | 07/27/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 146N00000X | 70.011421 | CT | N | Emergency Medical Service Providers | Emergency Medical Technician, Basic | 363A00000X | 23.002931 | CT | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.