Provider Demographics
NPI:1780645168
Name:GRIBBIN, THERESA R (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:R
Last Name:GRIBBIN
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31581 US HIGHWAY 19 N
Mailing Address - Street 2:
Mailing Address - City:PALM HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34684-3724
Mailing Address - Country:US
Mailing Address - Phone:727-772-0819
Mailing Address - Fax:
Practice Address - Street 1:31581 US HIGHWAY 19 N
Practice Address - Street 2:
Practice Address - City:PALM HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34684-3724
Practice Address - Country:US
Practice Address - Phone:727-772-0819
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2009-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9102943363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLQ34281Medicare UPIN
FLU4139ZMedicare PIN