Provider Demographics
NPI:1639192792
Name:GIBBENS, SHEILA O'SHEA (PA-C)
Entity Type:Individual
Prefix:
First Name:SHEILA
Middle Name:O'SHEA
Last Name:GIBBENS
Suffix:
Gender:F
Credentials:PA-C
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 1485
Mailing Address - Street 2:
Mailing Address - City:PENA BLANCA
Mailing Address - State:NM
Mailing Address - Zip Code:87041-1485
Mailing Address - Country:US
Mailing Address - Phone:505-467-1575
Mailing Address - Fax:505-467-1577
Practice Address - Street 1:820 PASEO DEPERLTA
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87501-2233
Practice Address - Country:US
Practice Address - Phone:505-467-1575
Practice Address - Fax:505-467-1577
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA2002-0013363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM64985768Medicaid
Q04529Medicare UPIN
341406202Medicare ID - Type Unspecified