Provider Demographics
NPI:1093181463
Name:GIBSON, EMILY MARION (PA-C)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:MARION
Last Name:GIBSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:EMILY
Other - Middle Name:MARION
Other - Last Name:WOODWARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:815 FREEPORT RD
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15215-3301
Mailing Address - Country:US
Mailing Address - Phone:412-784-5374
Mailing Address - Fax:
Practice Address - Street 1:815 FREEPORT RD
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15215-3301
Practice Address - Country:US
Practice Address - Phone:412-784-5374
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-19
Last Update Date:2023-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA057964208800000X
PA363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1031098860001Medicaid
PA454174SLVMedicare PIN