Provider Demographics
NPI:1063014413
Name:GIBB, BRYAN R (PA-C)
Entity Type:Individual
Prefix:MR
First Name:BRYAN
Middle Name:R
Last Name:GIBB
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:690 RIDGE RD APT 201
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:NY
Mailing Address - Zip Code:14882-8980
Mailing Address - Country:US
Mailing Address - Phone:850-368-1074
Mailing Address - Fax:
Practice Address - Street 1:16 BRENTWOOD DR STE A
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-1863
Practice Address - Country:US
Practice Address - Phone:607-272-7000
Practice Address - Fax:607-272-4604
Is Sole Proprietor?:No
Enumeration Date:2020-11-11
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant