Provider Demographics
NPI:1790760221
Name:GIBBONS, RICHARD
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:GIBBONS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3530 PEACH ST
Mailing Address - Street 2:SUITE LL1
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16508-2768
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:232 W 25TH ST
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16544-0002
Practice Address - Country:US
Practice Address - Phone:814-452-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-07
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA002697L363AM0700X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02922636Medicaid
NYPA2107Medicare PIN
NYPA2105Medicare PIN
NYPA2109Medicare PIN
NYQ19067Medicare UPIN
NY02922636Medicaid
NYPA2103Medicare PIN
NYPA2108Medicare PIN
NYPA2106Medicare PIN