Provider Demographics
NPI:1336142124
Name:GIBBONS, PATRICK JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:PATRICK
Middle Name:JOHN
Last Name:GIBBONS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8310
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24014-0310
Mailing Address - Country:US
Mailing Address - Phone:540-345-3556
Mailing Address - Fax:540-342-2193
Practice Address - Street 1:13700 ST FRANCIS BLVD
Practice Address - Street 2:SUITE 500
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23114-3222
Practice Address - Country:US
Practice Address - Phone:804-378-7443
Practice Address - Fax:804-378-0744
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2007-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101229755174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA006501478Medicaid
VAC09917Medicare PIN
VA006501478Medicaid
VAH35805Medicare UPIN