Provider Demographics
NPI:1417025750
Name:GIBBLE, SUSAN DENNIE (PA)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:DENNIE
Last Name:GIBBLE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 MEDICAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:SUPPLY
Mailing Address - State:NC
Mailing Address - Zip Code:28462-3350
Mailing Address - Country:US
Mailing Address - Phone:910-754-8921
Mailing Address - Fax:910-754-7140
Practice Address - Street 1:16 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:SUPPLY
Practice Address - State:NC
Practice Address - Zip Code:28462-3350
Practice Address - Country:US
Practice Address - Phone:910-754-8921
Practice Address - Fax:910-754-7140
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC100726363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCQ57979Medicare UPIN