Provider Demographics
NPI:1902813454
Name:BIRD, GINA C (PA)
Entity Type:Individual
Prefix:MS
First Name:GINA
Middle Name:C
Last Name:BIRD
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 W UNIVERSITY AVE
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61820-3909
Mailing Address - Country:US
Mailing Address - Phone:217-366-1248
Mailing Address - Fax:
Practice Address - Street 1:101 W UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-3981
Practice Address - Country:US
Practice Address - Phone:217-366-1248
Practice Address - Fax:217-366-6100
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2022-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085002358363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00168412OtherRAILROAD MEDICARE
IL434110OtherMEDICARE GROUP
IL0407950001Medicare NSC
IL434110OtherMEDICARE GROUP
ILQ34171Medicare UPIN