Provider Demographics
NPI:1154318251
Name:GIBBS, EMILIE KOEPKE (PA)
Entity Type:Individual
Prefix:
First Name:EMILIE
Middle Name:KOEPKE
Last Name:GIBBS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:EMILIE
Other - Middle Name:F
Other - Last Name:MAUKS-KOEPKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:10 QUEEN ST
Mailing Address - Street 2:
Mailing Address - City:NEWTOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06470-2156
Mailing Address - Country:US
Mailing Address - Phone:203-426-3267
Mailing Address - Fax:203-426-3903
Practice Address - Street 1:10 QUEEN ST
Practice Address - Street 2:
Practice Address - City:NEWTOWN
Practice Address - State:CT
Practice Address - Zip Code:06470-2156
Practice Address - Country:US
Practice Address - Phone:203-426-3267
Practice Address - Fax:203-426-3903
Is Sole Proprietor?:No
Enumeration Date:2005-10-04
Last Update Date:2018-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001401363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
290001401CT01OtherBLUE CROSS BLUE SHIELD
CT300461OtherPREFERRED ONE
CT2V2497OtherHEALTHNET
CT140100OtherCONNECTICARE
CTQ06724Medicare UPIN
290001401CT01OtherBLUE CROSS BLUE SHIELD