Provider Demographics
NPI:1720378862
Name:GIBB, ANDRIA MARIE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:ANDRIA
Middle Name:MARIE
Last Name:GIBB
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:ANDRIA
Other - Middle Name:MARIE
Other - Last Name:HICKEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 505164
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63150-5164
Mailing Address - Country:US
Mailing Address - Phone:417-829-4620
Mailing Address - Fax:417-829-4316
Practice Address - Street 1:2055 S FREMONT AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-2206
Practice Address - Country:US
Practice Address - Phone:417-820-2468
Practice Address - Fax:417-820-7794
Is Sole Proprietor?:No
Enumeration Date:2011-04-11
Last Update Date:2015-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011008542363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1720378862Medicaid
MO1720378862Medicaid