Provider Demographics
NPI:1730658436
Name:GIBBONS, MEGAN (PA-C)
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:
Last Name:GIBBONS
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 1:7328 KENT POINT RD
Mailing Address - Street 2:
Mailing Address - City:STEVENSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21666-3805
Mailing Address - Country:US
Mailing Address - Phone:443-472-6818
Mailing Address - Fax:
Practice Address - Street 1:5401 OLD COURT RD
Practice Address - Street 2:
Practice Address - City:RANDALLSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21133-5103
Practice Address - Country:US
Practice Address - Phone:410-521-2200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-26
Last Update Date:2018-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0007047363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical