Provider Demographics
NPI:1295988095
Name:GIHBSSON, PETA-GAY MCINTOSH (PA-C)
Entity type:Individual
Prefix:MRS
First Name:PETA-GAY
Middle Name:MCINTOSH
Last Name:GIHBSSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:PETA-GAY
Other - Middle Name:ANNICE
Other - Last Name:MCINTOSH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2100 POWELL ST
Mailing Address - Street 2:SUITE 900
Mailing Address - City:EMERYVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:94608-1826
Mailing Address - Country:US
Mailing Address - Phone:510-350-2600
Mailing Address - Fax:
Practice Address - Street 1:1798 N GAREY AVE
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767-2918
Practice Address - Country:US
Practice Address - Phone:909-865-9600
Practice Address - Fax:909-865-9623
Is Sole Proprietor?:No
Enumeration Date:2008-10-24
Last Update Date:2021-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA19806363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABB925ZMedicare PIN