Provider Demographics
NPI:1417127044
Name:GIBBS, PATRICK (PA)
Entity Type:Individual
Prefix:MR
First Name:PATRICK
Middle Name:
Last Name:GIBBS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 GLEASON DR
Mailing Address - Street 2:
Mailing Address - City:DIX HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11746-6536
Mailing Address - Country:US
Mailing Address - Phone:631-274-5946
Mailing Address - Fax:
Practice Address - Street 1:26 GLEASON DR
Practice Address - Street 2:
Practice Address - City:DIX HILLS
Practice Address - State:NY
Practice Address - Zip Code:11746-6536
Practice Address - Country:US
Practice Address - Phone:631-274-5946
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-11
Last Update Date:2012-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004043-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant