Provider Demographics
NPI:1083774509
Name:GIBBONS, ANDREA JO (RPA-C)
Entity Type:Individual
Prefix:MRS
First Name:ANDREA
Middle Name:JO
Last Name:GIBBONS
Suffix:
Gender:F
Credentials:RPA-C
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:21 WENMAN AVE
Mailing Address - Street 2:
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706-8923
Mailing Address - Country:US
Mailing Address - Phone:631-665-8034
Mailing Address - Fax:
Practice Address - Street 1:1175 MONTAUK HWY
Practice Address - Street 2:SUITE 4
Practice Address - City:WEST ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11795-4939
Practice Address - Country:US
Practice Address - Phone:631-422-9600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2014-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008888363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant