Provider Demographics
NPI:1376820340
Name:GIBSON, STACEY J (PA-C)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:J
Last Name:GIBSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:J
Other - Last Name:LORENZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:2030 THISTLE HILL DR STE 100
Mailing Address - Street 2:
Mailing Address - City:SPRING GROVE
Mailing Address - State:PA
Mailing Address - Zip Code:17362-1160
Mailing Address - Country:US
Mailing Address - Phone:717-225-9869
Mailing Address - Fax:717-225-6552
Practice Address - Street 1:2030 THISTLE HILL DR STE 100
Practice Address - Street 2:
Practice Address - City:SPRING GROVE
Practice Address - State:PA
Practice Address - Zip Code:17362-1160
Practice Address - Country:US
Practice Address - Phone:717-225-9869
Practice Address - Fax:717-225-6552
Is Sole Proprietor?:No
Enumeration Date:2011-11-04
Last Update Date:2021-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA055299363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA231023Medicare PIN