Provider Demographics
NPI:1770713901
Name:GIBSON, LAURA E (PA)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:E
Last Name:GIBSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:E
Other - Last Name:DUBENDORFER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 509
Mailing Address - Street 2:
Mailing Address - City:LIVINGSTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07039-0509
Mailing Address - Country:US
Mailing Address - Phone:800-345-0064
Mailing Address - Fax:973-251-1109
Practice Address - Street 1:176 PALISADE AVE
Practice Address - Street 2:CHRIST HOSPITAL
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07306-1121
Practice Address - Country:US
Practice Address - Phone:201-795-8200
Practice Address - Fax:973-251-1109
Is Sole Proprietor?:No
Enumeration Date:2009-07-22
Last Update Date:2013-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00222400363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ275041BC1Medicare PIN