Basic Information
| Provider Information | |||||||||
| NPI: | 1992157291 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRANDOLINO | ||||||||
| FirstName: | GINA | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 160 STONE ST | ||||||||
| Address2: | |||||||||
| City: | WATERTOWN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 136013250 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3157888065 | ||||||||
| FaxNumber: | 3152227432 | ||||||||
| Practice Location | |||||||||
| Address1: | 160 STONE ST | ||||||||
| Address2: | |||||||||
| City: | WATERTOWN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 136013250 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3157888065 | ||||||||
| FaxNumber: | 3152227432 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2016 | ||||||||
| LastUpdateDate: | 07/11/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | 382645 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
No ID Information.